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Health Assessment > Cardiac > Flashcards

Cardiac Flashcards

1
Q

What is the goal of pre-op cardiac assessment?

What are the 5 steps?

A
  • Goal: identify patients with heart disease who are at high risk for perioperative cardiac morbidity or mortality or those with modifiable conditions or risks
  • Steps:
      1. urgency of surgery
      1. determine if active cardiac condition
      1. determine surgical risk
      1. assess functional capacity
      1. assess clinical predictors/markers
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2
Q

What are the clinical predictors of minor increased cardiovascular risk (7)

What is the chance of having an event?

A
  • HTN
  • abnormal ECG
  • smoking
  • increased age/male sex
  • hypercholesterolemia
  • rhythm other than sinus
  • family history
  • <1% chance of having an event
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3
Q

What are the clinical predictors for an intermediate increase in cardiovascular risk?

A
  • Known CAD
  • prior MI > 1 month and Q waves on ECG
  • history of mild, stable angina
  • compensated or previous LV failure/CHF
  • diabetes
  • chronic renal insufficiency
    • Cr > 2.0 mg/dL
  • Cerebrovascular disease
    • stroke, TIA
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4
Q

What are the clinical predictors for a major cardiovascular risk?

A
  • unstable coronary syndromes
  • acute or recent MI <1 month
  • unstable or severe angina
  • decompensated CHF
  • significant arrhythmias
    • HB, afib (depending on how controlled the rate is), vtach
  • Severe valvular disease
    • mitral, aortic stenosis
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5
Q

What is the overall mortality risk of an acute MI after GA?

When is this risk increased?

A

0.3%

Incidence is increased in the patient undergoing intrathoracic or intra-abdominal surgery or surgery lasting longer than 3 hours.

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6
Q

What is the risk of mortality with history of prior MI?

> 6 months ago?

3-6 months ago?

within three months?

within 7 days?

If reinfarction occurs?

A
  • > 6 months ago: risk is 6%
  • 3-6 months ago: risk is 10%
  • within 3 months: 30%
  • within 7 days: postpone surgery
  • If reinfarction occurs, the mortality rate is 50%
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7
Q

What is the higherst risk period after an MI?

What are the ACC/AHA guidelines?

A
  • Highes risk period is within 30 days after an acute MI
  • ACC/AHA guidelines recommend waiting at least 4-6 weeks before elective surgery
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8
Q

Which surgeries are high risk?

intermediate risk?

low risk?

A
  • High:
    • intraperitoneal
    • intrathoracic
    • aortic and other major vascular
    • emergent major operations (esp in elderly)
    • long procedures with large fluid shifts/loss
  • Intermediate
    • Carotid endarterectomy
    • peripheral vascular surgery
    • head and neck
    • neurologic/ orthopedic
    • endovascular aneurysm repair
  • low
    • endoscopic procedures
    • superficial
    • biopsies
    • cataract
    • breast surgery, GYN
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9
Q

What is the “gold standard” test for coronary anatomy?

A

Coronary angiography

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10
Q

What do you want to try to figure out from the history, physical, and work up?

A
  • severity of cardiac disease
  • progression of the disease
  • what the patient’s functional limitations are
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11
Q

What are some questions you might want to ask a pt you suspect of having cardiac disease?

A
  • Do you become short of breath when lying flat (orthopnea) or with exertion?
  • Have you ever has a heart attack or CHF?
  • Do you have angina or chest pain/tightness?
    • what precipitates it?
    • what are some associated symptoms?
    • how frequent? duration?
    • what relieves the pain?
  • Do you have irregular heart beats or palpitations?
  • pacemaker? ICD?
  • heart murmor?
  • Problems with BP or on any meds?
  • PVD, TIA/CVA?
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12
Q

What are some more questions, not directly related to the heart that you would want to ask a cardiac patient?

A
  • DM?
  • renal insufficiency?
  • high cholesterol?
  • estrogen status? I.e. menopause- increased risk
  • age and weight?
  • fatigues?
  • syncope?
  • anemia?
  • smoker? alcohol?
  • illicit drug use?
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13
Q

How do you assess the pts functional capacity?

A
  • Exercise tolerance
    • if the pt has no lung disease, this is the most “striking” evidence of decreased cardiac reserve
  • Duke activity status Index
    • 1-4 METS: eating, dressing, walking around the house, dishwashing
    • 4-10 METS: climbing stairs, walk in neighborhood, heavy housework, golf, bowl, dance
    • >10: strenuous sports (swimming, tennis, running, football)
  • Those unable to meet a 4 MET demad are considered higher risk
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14
Q

What is a MET?

A
  • Metabolic equivalent of task
  • 1 MET = 3.5 mg/kg/min of O2 being consumed
  • 70 kg pt = 240 ml O2
    • ​This is the same minimum O2 flow required for a closed circuit
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15
Q

What is Angina?

What are some other causes of Angina?

Stats about silent MIs

A
  • Angina- sign of imbalance between myocardial oxygen supply vs demand
  • Other causes:
    • Aortic stenosis- may have angina despite normal coronaries
    • Esophageal spasm- caused by heartburn can cause angina that is relieved by NTG
  • Silent MIs
    • approximately 80% of ischemic episodes in CAD pts occur without angina
    • Approximately 10-15% of acute MIs are silent
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16
Q

What is prinzmetal’s angina?

A
  • Vasospastic angina that occurs at rest
  • 85% have a fixed proximal lesion in a major artery, 15% have just spasm
  • seen in pts with other vasospastic diseases:
    • migrains
    • Raynaud’s
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17
Q

What do you need to know/do if your patient has a pacemaker and ICD?

A
  • Indication for the pacemaker or ICD
  • underlying rhythm and rate
  • type of pacemaker
    • demand- sends electrical pulses if HR is too slow
    • fixed- constant frequency
    • radiofrequency- can be hacked
    • chamber paced vs chamber sensed
  • When was the last time the pacemaker was interrogated by CIED? -prefer within last 3 months
    • note settings and battery life
  • Evaluate effect of magnet
  • Inactivate ICD tachyarrhythmia detection and put defibrillator pads on
    • to avoid having the ICD pick up other electricity in OR as a dysrhythmia
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18
Q

What can inhibit pacemaker firing in the OR?

What is the magnet for?

What should you monitor?

A
  • Electrocautery can have electromagnetic interference that can inhibit pacemaker firing
    • Bipolar electrocautery is preferred; avoid monopolar
  • Most pacemakers can be converted to a fixed rate (asynchronous mode) by placing a magnet over the pacemaker box
    • must have a magnet immediately available
    • Have external pacing available
  • Monitor some form of blood flow
    • pulse ok, A-line
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19
Q

Where should the grounding pads be?

A

As far from the pulse generator and leads as possible

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20
Q

What are you going to look for upon physical exam of a patient with heart disease?

A
  • Overall appearance
    • obesity
    • SOB
    • sternal incision, pacemaker box
  • Heart
    • sounds
    • Murmors
  • Neck
    • JVD
    • Carotid bruit
  • Lungs
    • sounds
    • SOB, effort
  • Vital signs- BP in both arms
  • Extremeties
    • peripheral edema
    • pulses
    • clubbing
    • skin color
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21
Q

How do you assess the different heart sounds?

(pic)

What is Erb’s point?

A

Erb’s point is where you can hear S1 and S2 equally

22
Q

What is considered hypertension?

When should it be treated?

A
  • HTN is BP > 140/90
  • Treat if SBP >160 and DBP >90
    • Beta blockers may have protective benefit
23
Q

If pt has long standing severe HTN or uncontrolled HTN, what might you need to do?

A
  • May need to delay surgery to control BP
    • need ECG and serum BUN/Cr
    • if on diuretics, CHEM 7
  • continue meds
  • Anxiolytic may help
24
Q

What are the 2014 ACC/AHA recommendations regarding Beta blocker therapy?

A
  • Continue beta blocker therapy on pts who have been on chronic BB therapy
    • discontinuation may increase perioperative CV morbidity
  • Start BBs on high risk patients
    • >1 day prior to surgery, preferrably 2-7 days
    • can be harmful if started day of surgery
25
Q

What is heart failure?

What can cause it?

When is it suspected

A
  • Heart failure- abnormal contractility or abnormal relaxation of the heart muscle
    • can be causd by HTN or Ischemic heart disease (IHD)
  • Suspected with:
    • orthopnea
    • nocturnal coughing
    • fatigue
    • peripheral edema
    • 3rd, 4th heart sounds
    • resting tachycardia
    • rales
    • JVD
    • ascites
  • HF and LV dysfunction is high risk and elective surgery should be postponed
26
Q

What kind of work up do you want to do for a patient with Heart failure?

What meds do you want to continue before surgery?

A
  • ECG
  • Chem 7, BUN/Cr
  • BNP (normal = <100 pg/ml
  • CXR if you suspect pulmonary edema
  • ECHO to objectively measure LVEF
  • Continue all medications except ACEs and ARBs
27
Q

Which type of valvular abnormality poses the greatest risk?

What is the deal with diastolic murmors?

What if the pt has a prosthetic heart valve?

A
  • Aortic stenosis- valve area <1 cm2
    • if symptoms, postpone surgery
  • Diastolic murmors are always pathologic and require further evaluation
  • If pt has prosthetic heart valve
    • may need to bridge anticoagulant therapy
    • may need bacterial endocarditis prophylaxis
28
Q

Which arrhythmias are associated with perioperative risk?

CAD?

When should you postpone surgery?

A
  • SVT and ventricular arrhythmias are associated with perioperative risk
  • LBBB is strongly associated with CAD
    • if new, stress testing or consulatation is required
  • Postpone surgery if:
    • uncontrolled afib
    • ventricular tachycardia
    • new-onset atrial fibrillation
    • symptomatic bradycardia
    • high-grade or third degree HB
29
Q

What medications are ppl with cardiac issues typically on?

A
  • beta blockers
  • statins
  • aspirin
  • ACEIs/ARBS
  • CCB
  • nitro for angina
  • diuretics
  • antiarrhymics
30
Q

What anticoagulant medications might your patient be on and when should you have them stop taking them?

A
  • Antiplatelet (ASA, Plavix)
    • discontinue 7-10 days prior
  • Anticoagulants (coumadin, LMWH)
    • discontinue Coumadin 3-5 days prior
    • discontinue LMWH 12 hours prior
    • want INR <1.5
    • may use heparin gtt as bridge therapy, stop 4 hours prior to surgery
  • Fibrinolytics (TPA, Streptokinase, Urokinase)
    • usually cannot discontinue
31
Q

What can you see regarding the heart on a CXR?

Who should get one?

A
  • NOT specific for IHD, but can see:
    • cardiomegaly
    • pulmonary vascular congestion/pulmonary edema (CHF)
    • pleural effusions
  • Order CXR pre-op if:
    • pt is over 75 and is high risk
    • History of CHF
    • symptomatic cardiovascular disease
32
Q

What are the different classes for determining who should get an EKG?

A
  • Class I: Patient should get EKG
    • if pt has one or more: IHD, hx of heart failure, cerebrovascular disease, DM, renal insufficiency
    • And they are getting vascular surgery
  • Class IIa: It is reasonable to get EKG if:
    • pt has no clinical risk factors (above) but is getting a vascular surgical procedure
  • Class IIb: EKG may be considered if:
    • they have one or more risk factors (above) and are undergoing and intermediate-risk surgery
  • Class III: Should NOT be performed b/c it is not helpful
    • in pts who are asymptomatic and undergoing low-risk surgical procedures
33
Q

What do you review a 12-lead EKG to look for?

A
  • acute MI
  • prior MI
  • rhythm or conduction disturbances
  • cardiomegaly or ventricular hypertrophy
  • other EKG abnormalities; electrolyte imbalances
34
Q

What are the EKG indicators of acute ischemia?

A
  • ST segment elevation >/= 1 mm
  • T wave inversion
  • development of Q waves
  • ST segment depression, flat or downslope of >/= 1 mm
  • peaked T waves
35
Q

What leeds do you use to see:

Right side inferior of the heart (RCA)

Right side posterior of the heart (RCA)

A
  • Right inferior (RCA)
    • II, III, AVF
  • Right posterior (RCA)
    • V1, V2, V3
36
Q

What leeds do you use to see:

Left side anterior (LAD)

Left side antero-septal (LAD)

Left side lateral (LCA)

A
  • Left side anterior (LAD)
    • I, AVL, V1-V4
  • Left Antero-septal (LAD)
    • V1, V2, V3, V4
  • Left Lateral (LCA)
    • I, AVL, V5, V6
37
Q

How does treadmill exercise stress testing work?

What are you looking for?

How is it interpreted?

A
  • Stimulates sympathetic nervous system stimulation by increasing BP and HR and therefore increasing myocardial O2 demand and consumption
  • Look for ischemia by ECG changes
  • Interpretation based on:
    • duration of exercise the patient can perform
    • Max HR achieved
    • time of onset of ST depression
    • degree of ST depression
    • time until resolution of ST segment
38
Q

What is considered a positive treadmill stress test?

What is this indicative of?

A
  • Positive stress test: EKG signs
    • ST segment depression >2.5mm
    • ST depression occurs early in test (w/in first 3 minutes)
    • Serious ventricular arrhythmias
    • prolonged duration of ST depression in post recovery period
  • Non EKG:
    • If increase in BP or HR occurs at the time of ST depression
    • if hypotension occurs–this is an ominous sign
  • Indicative of CAD
39
Q

How is pharmacologic stress testing done?

A
  • IV injection of gamma-emitting radiopharmaceutical (thallium) that permits the imaging of blood within the heart and lungs
  • Dipyridamole or adenosine administered as a vasodilator to increase coronary blood flow
  • If area of decreased perfusion (cold spot) occurs only during stress, that shows ischemia
  • If cold spot is constant, that suggests old MI
    • this is a fixed defect, MI is already scarred
    • we prefer this because we can’t cause the problem?
  • Look for ischemia by perfusion imaging, not ECG changes
40
Q

When should you request stress testing?

A
  • Active cardiac condition
    • unstable coronary syndromes or severe angina
    • recent MI
    • decompensated HF
    • significant arrhythmias
    • Severe valvular disease
  • 3 or more clinical risk factors AND poor functional capacity having vascular surgery
  • Maybe if:
    • 1-2 clinical risk factors and poor functional capacity having intermediate risk surgery, if it will change management
    • 1-2 risk factors and good functional capacity having vascular surgery
41
Q

What will and ECHO tell you?

A
  • Measurement of dimensions of cardiac chambers and vessels and the thickness of myocardium
    • chamber enlargement
  • global ventricular systolic function: EF
  • regional wall motion abnormalities
  • valve structure and motion
  • blood flow and measure gradients
  • detect pericardial fluid
42
Q

What do you look for an a stress ECHO and what is that predictive of?

A
  • look for regional wall motion abnormalities under stress
  • An abnormal result consists of new or worsening of existing regional wall motion abnormalities during an infusion of dobutamine (exercise/stress)
  • Highly predictive of adverse cardiac events
43
Q

When should you order a pre-op echo?

A
  • Current or prior heart failure
    • w/ worsening dyspnea or other changes
    • to reassess LV dysfunction if they have previously documented LVD and it hasnt been reassessed for over a year
  • Dyspnea of unknown origin
  • clinically suspected valvular disease
    • significant change in symptoms
44
Q

What does Coronary angiography tell us?

A
  • diffuseness of obstructive disease
  • adequacy of any previous angioplasties or bypass grafts
  • CA spasms
  • LV pressures, volumes, and EF
    • LV dysfunctions- akinesis, dyskinesis, low EF, high LVEDF
  • Valve lumen and gradients
    • pressure gradients across valves and shunts, as well as degree of regurgitation
    • PA pressures
    • CO and SVR
  • Coronary angiography is the gold standard for cardiac anatomy and ppl undergoing cardiac surgery
45
Q

When should a pt have a pre-op cath?

A
  • Stable angina with left main CAD
  • stable angina with 3-vessel disease
  • stable angina 2-vessel disease with a significant proximal LAD lesion and EF <50% or ischemia on non-invasive stress testing
  • high risk unstable angina or non-ST elevation MI
  • Acute ST elevation MI
46
Q

How long should an elective procedure wait after a previous coronary intervention (revascularization)?

A
  • Balloon angioplast- wait at least two weeks
  • Bare-metal stent- wait at least 30-45 days
  • Drug-eluting stent- wait 365 days
47
Q

What can an MRI tell us about the heart?

A
  • Assess function and viability of myocardium
  • highly sensitive in detecting infarctions using gadolinium (contrast)
  • determine intracardiac tissue characterization
  • Looking for clots or tumors
48
Q

What are the different toolds used to assess cardiac risk?

A
  • Gupta perioperative cardiac risk tool
  • Revised cardiac risk index for pre-op risk (RCRI)
49
Q

Which kind of cardiac conditions should get subacute bacterial endocarditis (SBE) prophylaxis?

A
  • pts with high risk cardiac conditions associated with adverse outcomes from endocarditis
    • prosthetic heart valves
    • history of infective endocarditis
    • congenital heart disease
      • unrepaired cyanotic
      • if repaired with prosthetic material and within 6 months of repair
      • if repaired but still has residual defects
    • cardiac transplant
50
Q

If pts are high risk for SBE, which procedures do they need prophylactic antibiotics for?

A
  • all dental procedures that manipulate gingival tissue or perforation of oral mucosa
  • invasive respiratory tract procedures
    • tonsillectomy, adenoids, abscess drainage, lung biopsy
  • procedures involving infection of GI/GU tract, skin/musculoskeletal
    • not recommended in routine GI/GU
  • hepatobiliary procedures
  • cardiac surgery
51
Q

What are the standard SBE prophylaxis antibiotics and when are they administered?

A
  • given within 30-60 minutes before procedure or up to 2 hours after if missed before
  • medications:
    • ampicillin 2 gm (50 mg/kg peds)
    • Cefazolin 1 gm (50 mg/kg peds
    • Ceftriaxone 1 gm (50 mg/kg peds)
    • If PCN allergic, Clindamycin 600 mg )20 mg/kg peds)

Health Assessment (14 decks)

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