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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 “A neutron walked into a bar and asked how much for a drink. The bartender replied, "for you, no charge." -Jaime - Internet Chemistry Jokes 2 ACID/BASE BALANCE AND THE BLOOD [H+] [OH -] Acidic Alkaline (Basic) Neutral pH 0 Venous Blood Arterial Blood 14 Acidosis 6.8 7 7.4 Normal7.35-7.45 Alkalosis 8.0 3 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 4 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- 5 Control of Acids 1. 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 6 7 Acidosis (392) Principal effect of acidosis is depression of the CNS through ↓ in transmission. Generalized weakness Deranged CNS function is the greatest threat Severe acidosis causes synaptic Disorientation coma death 8 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 9 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. 10 11 ELECTROLYTES Calcium (428-429) Sodium(430) Potassium(175) Magnesium(148) Phosphorus(170) 12 Uncorrected electrolyte abnormalities may have lifethreatening consequences. Important electrolytes includecalcium (Ca), potassium (K), sodium (Na) and magnesium (Mg) 13 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 14 Hypercalcemia Causes Hyperparathyroidism Cancer with bone metastasis (in particular prostate and breast) 15 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) 16 Hypokalemia Causes Defined as: Drugs (diuretics, beta Mild: 3-3.2 mmol/L agonists) Diarrhea (laxative abuse) Moderate: 2.5-2.9 mmol/L Diabetes (uncontrolled) Severe: <2.5 mmol/L Inadequate intake Symptoms May vary from asymptomatic to fulminant respiratory failure Most commonly manifests as weakness, fatigue EKG – prolonged QT, Torsade de Pointes 17 HYPERKALEMIA Causes: Defined as: Metabolic acidosis Mild: >5.1-6.0 mmol/L Hypoglycemia Rhabdomyolysis Moderate: 6.1-7 mmol/L Tumor lysis syndrome Severe: >7 mmol/L Drugs Symptoms Renal failure Usually only occur above 7 mmol/L Muscle weakness, cardiac arrhythmias EKG – peaked waves, widening of QRS 18 Sodium (Na) Normal range: 136-144 mmol/L Sodium-related disorders Hyponatremia 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 Defined as <136 mmol/L Symptoms Headache, nausea, emesis, lethargy Severe hyponatremia can cause seizures, coma, death 19 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 20 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 21 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) 22 Hypermagnesemia Causes Impaired renal function Patient receiving large load of magnesium or magnesiumcontaining 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 23 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 24 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 25 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 26 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) 27 Hyperphosphatemia May be due to or associated with: Kidney failure Hypoparathyroidism (underactive parathyroid gland) Diabetic ketoacidosis (when first seen) Phosphate supplementation 28 Cardiovascular Tests 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 <100 100-129 130-159 160-189 190 Optimal Near Optimal/Above Optimal Borderline High High Very high 30 Total Cholesterol <200 • 200-239 240 HDL Cholesterol <40 60 Desirable Borderline High High Low High 31 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. 32 Identify metabolic syndrome and treat, if present, after 3 months of TLC. Clinical Identification of the Metabolic Syndrome - Any 3 of the Following: Risk Factor Defining Level Abdominal obesity* Men Women Waist circumference** >102 cm (>40 in) >88 cm (>35 in) Triglycerides HDL cholesterol Men Women 150 mg/dL <40 mg/dl <50 mg/dl blood pressure 130/ 85 mmHg Fasting glucose 110 mg/dL 33 Treat elevated triglycerides. (207) ATP III Classification of Serum Triglycerides (mg/dL) < 150 150-199 200-499 500 Normal Borderline high High Very high 34 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. 35 High Risk Group 1. 2. 3. 4. 5. 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% 36 Characterized by five major abnormalities 1. 2. 3. 4. 5. Obesity (central body and visceral) Hypertension Insulin resistance (hyperinsulinemia) Glucose intolerance Dyslipidaemia 37 Emerging Risk Factors Lipoprotein (a) C-reactive protein (66) Homocysteine (133) Prothrombotic factors Proinflammatory factors Impaired fasting glucose Subclinical atherosclerosis 38 OTHER PREDICTORS CHD risk factors 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. 40 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. 41 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) 42 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. 43 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 44 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) 45