Cardiac Assessment Flashcards
1
Q
What can be used to identify the patients at risk for perioperative cardiac morbidity and mortality?
A
CARDIAC EVALUATION ALGORITHM
- Urgency: “life or limb”
- emergent ( <6 hrs)
- Urgent (6-24 hrs )
- Active cardiac conditions
- Unstable Coronary Syndromes
- Valvular disease
- Significant arrhythmias
- Decompensated HF
- Recent MI < 1 mo
- Pulmonary HTN
- Risk- surgical risk
- Low risk: cataracts, endoscopic, breast, superficial, ambulatory
- Intermediate (ICHOP): intrathoracic, intraabdominal, head & neck, ortho, prostate
- High risk: aortic and peripheral vascular sx
- Functional limitation = METS
- Use METs to determine their functional capacity
- > 4 METs → proceed
- < 4 METs → additional testing (stress testing)
- EXERCISE TOLERANCE → automatically MET 5
- Use METs to determine their functional capacity
- Predictors/markers
- General risk factors for INCREASED periop cardiac m/m
- IHD
- Prior CHF
- CVA
- Renal insufficiency (> 2 creatinine)
- DM
2
Q
What are some cardiac conditions that would require you to delay or cancel surgery?
A
- Active cardiac conditions
- Unstable Coronary Syndromes → Acute/unstable Angina (greatest risk)
- Valvular disease- AS or MS
- Significant arrhythmias- Mobitz II, CHB, SVT, AF with RVR, bradycardia, new VT
- Decompensated HF - new onset; NYHA class IV
- Recent MI < 1 mo
- Pulmonary HTN
3
Q
RECOMMENDATIONS FOR PREOP 12 LEAD:
A
- IIa: reasonable to perform 12-lead → IHD, Significant arrhythmia, PAD, CVD. Significant structural HD (unless low risk procedure)
- IIb: Considered 12-lead → asymptomatic pts w/o known coronary heart disease, (except low risk sx)
- III: NOT BE PERFORMED → not helpful for asymptomatic pts undergoing low risk procedure
4
Q
Describe the differences between stable and unstable angina.
A
- Stable Angina: substernal discomfort on EXERTION
- Relieved by NTG and rest in < 15 min
- Symptoms:
- radiation to jaw
- shoulder, neck
- inner aspect of arm
- Poses no greater threat to perioperative MI than absence of anginal symptoms
- Unstable angina
- Newly developed w/in past 2 months and angina that last >30 min
- Worsened in intensity, frequency, duration
- Less responsive to meds
- a/w highest risk for periop MI
- Present in EKG: NOT labs
- ST or T wave changes without increase in cardiac enzymes
- Unstable angina→ cancel elective sx until evaluated
- Workup- coronary angio, exercise EKG stress test
5
Q
Things to inquire the patient about if they have a pacemaker or ICD.
A
- Indication for pacemaker/ICD
- Underlying rhythm and rate
- Type of pacemaker (demand/fixed), chamber placed, and chamber sensed
- Does your heart ever beat on its own? Are you completely dependent on it?
- Has it been interrogated by a qualified member of CIED
- Note battery life and settings
- Pacemakers: needs to be evaluated w/in 12 mo before sx
- ICD: evaluated win 6 mo of elective sx
- Note battery life and settings
- Evaluate effect of magnet
- Inactivate ICD tachyarrhythmia detection and put defibrillator pads on
6
Q
Perioperative considerations for pacemaker and ICD?
A
- Pacemakers need to be placed in asynchronous mode, or a magnet placed over the device
- Demand pacemakers can sense the electrocautery which will inhibit pacemaker firing and cause asystole
- If magnet used, make sure it automatically reset to preop settings once magnet removed
- ICD devices need to have tachyarrhythmias turned off and pacemaker function set to asynchronous mode (ensure defib pads on)
- Prevent unwanted shocks that signals might interpret as VT/VF
- Ensure monitor enabled to displace pacer spikes
- Have magnet available
- Place grounding pads as far away from pulse generator and leads as possible
- Bipolar electrocautery preferred; avoid monopolar
- Monitor blood flow (pulse ox, intra-arterial BP)
- Have external pacing and crash cart available.
7
Q
What are some potential palpation findings on a cardiac assessment?
A
Palpation
- PMI (< 2.5cm) – point of maximal impulse (~size of quarter)
- Cardiac Apex: The tapered inferior tip of the left ventricle → **produces the apical impulse
- Children/Young adults: PMI easy to visualize/palpate
- As chest deepens the AP diameter → impulse harder to find
- Normal Location:
- Located 5th intercostal space, midclavicular line
- Supine= the normal PMI about the size of a quarter (~1-2.5 cm).
- Abnormal PMI locations:
- Right ventricular Hypertrophy- shifted to xiphoid or epigastric area
- Ventricular dilation (HF, cardiomyopathy, IHD)- displaced laterally toward axilla
- Pregnancy- shift apical impulse upward and left
- Normal Location:
- Thrills- vibratory/buzzing sensations caused by underlying turbulent flow
8
Q
Describe the auscultation assessment of the heart
A
- Aortic valve - 2nd ICS, RSB
- Pulmonary valve: 2nd ICS, LSB
- Erb’s point: 3rd ICS, LSB
- Tricuspid Valve: 4th ICS, LSB
- Mitral valve: 5th ICS, MCL
- S1- mitral and tricuspid closure → ventricular systole
- S2- aortic and pulmonary valve closure → ventricular diastole
9
Q
Describe some common heart murmurs.
A
- Aortic stenosis
- Timing- midsystolic
- Radiation- often to the carotids (neck)
- Aortic regurg
- Timing- holodiastolic
- Radiation- often to carotids, if loud→ apex
- Mitral stenosis
- Timing- middiastolic
- Radiation- little to none
- Mitral regurg
- Timing- holosystolic
- Radiaiton- to the left axilla
- Mitral valve prolapse
- Timing- midsystolic click
- Radiation- no radiation, but ballooning of the mitral valve into the left atrium
10
Q
Your patient has hypertension. What preoperative tests do you anticipate ordering? What medications should be continued/held?
A
- EKG
- BUN/Creatinine
- If on diuretics → BMP/CMP
- Meds:
- CONTINUE: BB, CCB
- D/C: ACEI, ARBS
11
Q
Your patient has the results for a stress test. What are the indicators for a positive stress test?
A
- EKG criteria
- ST elevation > 1 mm
- ST depression > 0.2 mm (w/in 1st 3 min)
- Serious ventricular arrhythmias
- Unusual S/S:
- angina
- breathlessness
- cold sweats
- pallor
- cynosis
- Non-EKG responses
- No increase in SBP
- Progressive fall in SBP
- Elevated DBP
12
Q
When is ordering a stress-test appropriate?
A
- unstable coronary syndromes
- unstable or severe angina
- recent MI
- decompensated HF
- significant arrhythmias (SVT, a fib, 3rd deg HB)
- severe valvular disease
13
Q
What can an echocardiography show?
A
- Measure dimensions of cardiac chambers, vessels, and thickness of myocardium
- Global ventricular systolic function: EF
- Wall motion abnormalities
- Valve structure/motion
- Blood flow/measure gradients
- Chamber enlargement
- Pericardial fluid detection
14
Q
What patients require subacute bacterial endocarditis prophylaxis?
A
- Prophylaxis patients with high risk cardiac conditions associated with high risk of adverse outcomes for infective endocarditis:
- Prosthetic valves
- History of infective endocarditis
- Congenital heart disease
- Unrepaired cyanotic heart disease
- Repaired congenital heart defects with prosthetic material/device < 6mo
- Repaired with residual defects
- Damaged heart valves
- CV transplantation with cardiac valvular disease
- Hypertrophic cardiomyopathy
15
Q
For which procedures is Subacute Bacterial Endocarditis Prophylaxis recommended?
A
- All dental/oral procedures involving manipulation/perforation of gingival tissue or oral mucosa
- Invasive respiratory tract procedures with perforation of respiratory mucosa
- Procedures involving infection of GI/GU tract, skin/musculoskeletal tissue
- NOT recommended in routine GU/GI tract sx or bronch
- Hepatobiliary procedures with high risk bacteremia
- Cardiac sx
