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Electrolyte disturbances Cardiovascular Tests. Definitions!. Protons + are positively charged particles ( atomic number is the number of protons) example H+ Electrons - are the negatively charged particles that spin Neutrons uncharged particles that spin and are made up of quarks

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definitions
Definitions!
  • Protons + are positively charged particles (atomic number is the number of protons) example H+
  • Electrons - are the negatively charged particles that spin
  • Neutronsuncharged particles that spin and are made up of quarks
  • “A neutron walked into a bar and asked how much for a drink. 
  • The bartender replied,  "for you, no charge." 

-Jaime - Internet Chemistry Jokes

acid base balance and the blood
ACID/BASE BALANCE AND THE BLOOD

[H+]

[OH -]

Acidic

Alkaline (Basic)

Neutral

pH

7

Venous Blood

Arterial Blood

0

14

Acidosis

Alkalosis

7.4

DEATH

DEATH

Normal7.35-7.45

6.8

8.0

small changes in ph can produce major disturbances
Small changes in pH can produce major disturbances
  • Most enzymes function only with narrow pH ranges
  • Acid-base balance can also affect electrolytes (Na+, K+, Cl-)
  • Can also affect hormones
the body produces more acids than bases
The body produces more acids than bases
  • Acids take in with foods
  • Acids produced by metabolism of lipids and proteins
  • Cellular metabolism produces CO2.
  • CO2 + H20 ↔ H2CO3 ↔ H+ + HCO3-
control of acids
Control of Acids
  • Buffer systems

Take up H+ or release H+ as conditions change

Buffer pairs – weak acid and a base

Exchange a strong acid or base for a weak one

Results in a much smaller pH change

acidosis 392
Acidosis (392)
  • Principal effect of acidosis is

depression of the CNS through ↓ in synaptic transmission.

  • Generalized weakness
  • Deranged CNS function is

the greatest threat

  • Severe acidosis causes
    • Disorientation
    • coma
    • death
alkalosis
Alkalosis
  • Alkalosis causes over excitability of the central and peripheral nervous systems.
  • Numbness
  • Lightheadedness
  • It can cause :
    • Nervousness
    • muscle spasms or tetany
    • Convulsions
    • Loss of consciousness
    • Death
anion gap
Anion Gap
  • The difference between [Na+] and the sum of [HC03-] and [Cl-].
      • [Na+] – ([HC03-] + [Cl-]) =
        • 140 - (24 + 105) = 11
          • Normal = 12 + 2
  • Clinicians use the anion gap to identify the cause of metabolic acidosis.
electrolytes
ELECTROLYTES
  • Calcium (428-429)
  • Sodium(430)
  • Potassium(175)
  • Magnesium(148)
  • Phosphorus(170)
slide13
Uncorrected electrolyte abnormalities may have life-threatening consequences. 
  • Important electrolytes include-
  • calcium (Ca),
  • potassium (K),
  • sodium (Na) and
  • magnesium (Mg)
calcium
CALCIUM
  • Hypocalcemia
  • Symptoms
    • Tetany, seizures
    • Circumoral numbness
    • Paresthesias
    • Carpopedal spasm
    • Latent tetany may result in Trousseau and Chvostek signs
    • Electrocardiogram (EKG) – prolonged QT, Torsades de Pointes
hypercalcemia
Hypercalcemia
  • Causes
  • Hyperparathyroidism
  • Cancer with bone metastasis (in particular prostate and breast)
potassium k
Potassium (K)
  • Cellular distribution affected by insulin and beta-adrenergic receptors, renal excretion
  • 3 mechanisms control potassium
  • Intake
  • Distribution between intracellular and extracellular fluid
  • Renal excretion
  • Rapid changes have life-threatening consequences
  • May affect serum pH (inverse relationship)
hypokalemia
Hypokalemia

Causes

Drugs (diuretics, beta agonists)

Diarrhea (laxative abuse)

Diabetes (uncontrolled)

Inadequate intake

  • Defined as:
    • Mild: 3-3.2 mmol/L
    • Moderate: 2.5-2.9 mmol/L
    • Severe: <2.5 mmol/L
  • Symptoms
  • May vary from asymptomatic to fulminant respiratory failure
  • Most commonly manifests as weakness, fatigue
  • EKG – prolonged QT, Torsade de Pointes
hyperkalemia
HYPERKALEMIA

Causes:

Metabolic acidosis

Hypoglycemia

Rhabdomyolysis

Tumor lysis syndrome

Drugs

Renal failure

  • Defined as:
  • Mild: >5.1-6.0 mmol/L
  • Moderate: 6.1-7 mmol/L
  • Severe: >7 mmol/L
  • Symptoms
  • Usually only occur above 7 mmol/L
  • Muscle weakness, cardiac arrhythmias
  • EKG – peaked waves, widening of QRS
sodium na
Sodium (Na)

Causes:

thiazide diuretics, osmotic diuresis, adrenal insufficiency, ketonuria

syndrome of inappropriate antidiuretic hormone (SIADH), hypothyroidism, HIV, certain forms of cancer

psychogenic polydipsia, multiple tap water enemas, congestive heart failure

  • Normal range: 136-144 mmol/L
  • Sodium-related disorders
  • Hyponatremia
    • Defined as <136 mmol/L
    • Symptoms
    • Headache, nausea, emesis, lethargy
    • Severe hyponatremia can cause seizures, coma, death
hypernatremia
Hypernatremia
  • Defined as serum sodium >144 mmol/L
  • Symptoms:
  • Mimics symptoms of hyponatremia
  • Causes
  • Insensible losses (e.g., fever)
  • Diabetes insipidus (central, nephrogenic)
  • Cushing disease
  • Hyperaldosteronism
magnesium mg
Magnesium (Mg)
  • Physiologically – magnesium aids in cellular transport of Ca, Na, K
  • Balance maintained by kidneys
  • Normal range in serum: 1.6-2.6 mg/dL
hypomagnesemia
Hypomagnesemia

Causes

Gastrointestinal losses – diarrhea, small bowel surgery, malabsorption, pancreatitis

Renal losses – diuretics, nephrotoxic drugs, tubular necrosis

Uncontrolled diabetes mellitus

  • Is a common disorder
  • Symptoms
  • Neurologic manifestations similar to hypocalcemia
  • Tetany, muscle weakness, Chvostek and Trousseau signs
  • EKG – widening QRS or QT and peaked T waves, premature ventricular contractions (PVCs)
hypermagnesemia
Hypermagnesemia

Causes

Impaired renal function

Patient receiving large load of magnesium or magnesium-containing drugs

Parenteral magnesium therapy for preeclampsia

Elderly patients with gastrointestinal disease on cathartics

  • Defined as serum Mg >2.6 mg/dL
  • Symptoms
  • Usually mild elevation and therefore no symptoms
  • Symptoms when Mg ≥4 mg/dL
    • 4-6 mg/dL: nausea, lethargy, flushing
    • 6-10 mg/dL: somnolence, hypocalcemia, hypotension, bradycardia
    • >10 mg/dL: respiratory paralysis, complete heart block, cardiac arrest
phosphorus
Phosphorus
  • Phosphates are vital for energy production, muscle and nerve function, and bone growth
  • An important role as a buffer, helping to maintain the body’s acid-base balance
  • 70% to 80% as calcium phosphate – bones/teeth
  • 10% in muscle
  • 1% in nerve
  • Beans, peas and nuts, cereals, dairy products, eggs, beef, chicken, and fish contain significant amounts of phosphorus
  • Intestinal absorption and renal excretion maintains blood levels
phosphorus1
Phosphorus
  • Phosphorus testing often is performed as a follow-up to an abnormal calcium level and/or related symptoms, such as fatigue, muscle weakness, cramping, or bone problems
  • To ensure patient is not excreting or retaining excessive amounts in the presence of kidney disorder, kidney stones, or uncontrolled diabetes
phosphorus2
Phosphorus
  • Also known as P, PO4, Phosphate
  • When to get tested?
  • As a follow-up to:
  • an abnormal calcium level
  • kidney disorder
  • uncontrolled diabetes, and
  • On calcium or phosphate supplements
hypophosphatemia
Hypophosphatemia
  • Dietary deficiencies in phosphorus are rare but may be seen with alcoholism and malnutrition
  • May be associated with:
  • Hypercalcemia, especially due to hyperparathyroidism
  • Overuse of diuretics
  • Severe burns
  • Diabetic ketoacidosis (after treatment)
  • Hypothyroidism
  • Hypokalemia
  • Chronic antacid use
  • Rickets and osteomalacia (due to Vitamin D deficiencies)
hyperphosphatemia
Hyperphosphatemia
  • May be due to or associated with:
  • Kidney failure
  • Hypoparathyroidism (underactive parathyroid gland)
  • Diabetic ketoacidosis (when first seen)
  • Phosphate supplementation
step 1 determine lipoprotein levels obtain complete lipoprotein profile after 9 to 12 hour fast 78
STEP 1: Determine lipoprotein levels - obtain complete lipoprotein profile after 9- to 12-hour fast (78)
  • ATP III Classification of LDL, Total, and HDL Cholesterol (mg/dL)
  • LDL Cholesterol - Primary Target of Therapy
determine presence of major risk factors
Determine presence of major risk factors
  • Major Risk Factors (Exclusive of LDL Cholesterol)

That Modify LDL Goals

  • Cigarette smoking
  • Hypertension (BP 140/90 mmHg or on antihypertensive medication)
  • Low HDL cholesterol (<40 mg/dl)*
  • Family history of premature CHD (CHD in male first degree relative <55 years; CHD in female first degree relative <65 years)
  • Age (men 45 years; women 55 years)
  • * HDL cholesterol 60 mg/dL counts as a "negative" risk factor; its presence removes one risk factor from the total count.
  • Note: in ATP III, diabetes is regarded as a CHD risk equivalent.
identify metabolic syndrome and treat if present after 3 months of tlc
Identify metabolic syndrome and treat, if present, after 3 months of TLC.

Clinical Identification of the Metabolic Syndrome - Any 3 of the Following:

treat elevated triglycerides 207
Treat elevated triglycerides. (207)

ATP III Classification of Serum Triglycerides (mg/dL)

coronary risk screen
Coronary Risk Screen
  • CHOLESTEROL: is normally synthesized by the liver and is important as a constituent of cell membranes and a precursor to steroid hormones. Its level in the bloodstream can influence the pathogenesis of certain conditions, such as the development of atherosclerotic plaque and coronary artery disease
  • TRIGLYCERIDES: Triglycerides are esters of glycerol and fatty acids. Since they and cholesterol travel in the blood stream together, they should be assessed together.
  • HDL: A complex of lipids and proteins in approximately equal amounts that functions as a transporter of cholesterol in the blood. High levels are associated with a decreased risk of atherosclerosis and coronary heart disease.
  • LDL: A complex of lipids and proteins, with greater amounts of lipid than protein, which transports cholesterol in the blood.
  • CHOL/HDL RATIO: A ratio of lipids for determining possible cardiac risk factors.
high risk group
High RiskGroup
  • Have either CAD or any one of five CAD "risk equivalents":
  • Diabetes mellitus
  • Peripheral vascular disease
  • Carotid artery disease
  • Abdominal aortic aneurysm
  • A calculated 10-year risk for a coronary event that exceeds 20%
characterized by five major abnormalities
Characterized by five major abnormalities

1.   Obesity (central body and visceral)

2.   Hypertension

3.   Insulin resistance (hyperinsulinemia)

4.   Glucose intolerance

5. Dyslipidaemia

emerging risk factors
Emerging Risk Factors
  • Lipoprotein (a)
  • C-reactive protein (66)
  • Homocysteine (133)
  • Prothrombotic factors
  • Proinflammatory factors
  • Impaired fasting glucose
  • Subclinical atherosclerosis
other predictors

OTHER PREDICTORS

CHD risk factors

tests for acute heart attacks myocardial infarction
TESTS FOR ACUTE HEART ATTACKS (MYOCARDIAL INFARCTION)
  • CK-II MB (CREATININE KINASE) (88)
  • TROPONINS(209)
  • Creatine Kinase (CK)(87)
  • CK is an enzyme found in the heart and muscles. Increased CK-MB is seen with heart muscle damage.
  • Increased CK-MM is noted with skeletal muscle injury. Strenuous exercise, weight lifting, surgical procedures, high doses of aspirin and other medications can elevate CK.
troponin t ctnt
Troponin T (cTNT)
  • Troponin T is a protein found in the blood and is related to contraction of the heart muscle.
  • Troponin T is valuable for detecting heart muscle damage and risk.
ultra sensitive c reactive protein us crp 66
Ultra Sensitive C-reactive Protein (US-CRP)(66)
  • Goal values:
  • Less than 1.0 mg/L = Low Risk for CVD
  • 1.0-2.9 mg/L = Average Risk for CVD
  • Greater than 3.0 mg/L High Risk for CVD
  • (levels above these ranges indicate increased risk for heart and blood vessel disease)
b type natriuretic peptide bnp blood test
B-Type Natriuretic Peptide (BNP) blood test
  • BNP is a substance secreted from the ventricles or lower chambers of the heart in response to changes in pressure that occur when heart failure develops and worsens.
  • Increases when heart failure symptoms worsen, and decreases when the heart failure condition is stable.
b type natriuretic peptide bnp blood test1
B-Type Natriuretic Peptide (BNP) blood test
  • BNP levels below 100 pg/mL indicate no heart failure
  • BNP levels of 100-300 suggest heart failure is present
  • BNP levels above 300 pg/mL indicate mild heart failure
  • BNP levels above 600 pg/mL indicate moderate heart failure.
  • BNP levels above 900 pg/mL indicate severe heart failure.
  • BNP accurately detected heart failure 83% of the time and reduced clinical indecision from 43% to 11%.

-January 2008 issue of the Journal of the American College of Cardiology

homocysteine hcy 133
Homocysteine (Hcy) (133)
  • An amino acid. High levels are related to early development of heart and blood vessel disease
  • Goal value: less than 10 umol/L
  • High levels of homocysteine are related to the early development of heart and blood vessel disease. In fact, it is considered an independent risk factor for heart disease.
  • High homocysteine is associated with low levels of vitamin B6, B12 and folate and renal disease.
  • For the most accurate results, wait at least two months after a heart attack, surgery, infection, injury or pregnancy to check this blood level.
  • Evaluation of hyperlipidemia (431)
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