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AFN Health Assessment > Cardiac Assessment Part 2 > Flashcards

Cardiac Assessment Part 2 Flashcards

1
Q

What valve issue?

May be asymptomatic until severe

Symptoms

angina, syncope, CHF
Exercise testing for CAD has poor diagnostic accuracy
should not be performed in symptomatic patients

A

Aortic stenosis

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2
Q

HR where ischemia occurs

A

Ischemic threshold

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3
Q

(T/F) LBBB is always indicative of abnormal pathology

A

True

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4
Q

With aortic stenosis avoid drugs that increase ___, decrease ____ and _________

A

HR
SVR
Preload

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5
Q

What valve disease?

Often no symptoms until severe dz
Symptoms

pulmonary edema, dyspnea, PND
chest pain, palpitations, AF
hemoptysis, hoarseness (Ortner’s syndrome)

A

Mitral stenosis

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6
Q

Classification of valve stenosis (aortic & mitral)

Valve area = >1.5 cm^2

A

Mild

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7
Q

Classification of valve stenosis (aortic & mitral)

Valve area = 1-1.5 cm^2

A

Moderate

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8
Q

Classification of valve stenosis (aortic & mitral)

Valve area = <1 cm^2

A

Severe

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9
Q

Understand Pressure-volume loops

A

Research it

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10
Q

What valve disease?

Chronic versus Acute
Graded from 1+ to 4+
Hemodynamic goals
maintain preload
increase HR>/= 80 pm
what about ASCVD
maintain contractility
decrease afterload

A

Aortic Regurg

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11
Q

Is frank-starling mechanism intrinsic or extrinsic?

A

Intrinsic

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12
Q

What valve disease?

Acute:

papillary muscle dysfunction- chest trauma or MI, myxomatous disease
Sudden increase in LAP – pulmonary circuit
Presents as bivent failure

A

Acute mitral regurg

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13
Q

What valve disease?

Chronic:

LV dilation, RHD, chordae thickening
Eccentric hypertrophy and LAE
Compensated vs. decompensated

A

Chronic mitral regurg

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14
Q

With mitral regurg, avoid anything that increases _____!

A

PVR

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15
Q

Review classifications of heart failure. NYHA classification scale is very common, but know both NYHA & ACC/AHA. Seen on slide 61 on PP.

A

Slide 61

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16
Q

With MR, maintain preload, but be careful not to ________

A

overload

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17
Q

What type of heart dysfunction?

Chronic increased afterload
Increased wall thickness with no change in chamber size
Diminished compliance

A

Concentric Hypertrophy

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18
Q

Pt in HF are much more depend on _____ kick than the normal pt. Therefore, watch out for what arrhythmia?

A

Atria kick
Afib

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19
Q

IF possible, use nerve _____ for pain management for cardiac pts to help alleviate pain.

A

Nerve blocks

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20
Q

What type of heart dysfunction?

Dilated LV
chronic increase in volume
Increased wall thickness with an increase in chamber size

A

Eccentric Hypertrophy

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21
Q

What type of heart dysfunction? (take your time and read the symptoms/presentations)

Dynamic stenosis with varying degrees of obstruction
nonobstructive, labile, or obstructive
Sudden death may be the first manifestation of the disease
Potential mechanisms include atrial arrhythmias with sudden hypotension. LVOT obstruction exacerbated by brady or tachy arrhythmias, or myocardial ischemia
May have total obstruction to Ao outflow
asymm hypertrophy of intraventricular septum
anterior displacement of papillary m and MV leaflets (SAM)
Mitral Regurgitation

A

Hypertrophic Subaortic Stenosis (HOCM)

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22
Q

New or worsened HF within ___ weeks of non-cardiac surgery leads to a 2x increase of 30-day mortality

A

4 weeks

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23
Q

Who decides if a cardiac pt is cleared for surgery?

A

YOU (bring up convo w/ surgeon)

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24
Q

HOCM Preoperative Considerations? (List at least 3)

A

-continue all meds incl. antiarrhythmics
-avoid hypovolemia
-avoid tachycardia & sympathetic stimulation
-all types of anesthesia are acceptable
-Ca++ / BB?

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25
Q

Serotonin causes ______ stenosis

A

Tricuspid

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26
Q

Your biggest job to identify w/ aortic stenosis pts.?

A

Symptomatic or non symptomatic

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27
Q

With AS, the after load comes from the ______

A

aortic valve

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28
Q

With increase SVR, the after load comes from the _____

A

vascular system

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29
Q

Give vasodilators with AS?

A

Nooo

Problem is not the vasculature (SVR)
Will bottom out BP and cardiac perfusion

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30
Q

AS can pull volume out of the ______ arteries via the venturi effect

A

coronary

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31
Q

With AS, monitor BP with ____ ____

A

A line

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32
Q

Induction should be ______ and steady with AS and cardiac pts

A

Slow

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33
Q

Narcotics are ______ stable

A

Cardiac stable

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34
Q

What drug for SVR increase in cardiac pt.?

A

Neo (not levo, will increase HR)

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35
Q

Cardiac murmurs overview. Looks at slide 81 on PP

A

Review slide 81 on PP

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36
Q

Stretch of the left recurrent laryngeal nerve

A

Ortners syndrome

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37
Q

You can see _______ syndrome with MS pts

A

Ortners syndrome

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38
Q

Have big left _____ chamber with MS pts

A

left atrium

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39
Q

Normal aortic valve size

A

3-4 cm^2

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40
Q

Critical aortic stenosis valve size?

A

<0.7

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41
Q

Mean AV gradient gives you reflection of ___ dysfunction

A

LV dysfunction

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42
Q

Sever AV area paired w/ moderate AV mean gradient. What does pt. probably need?

A

Needs inotrope

Prob have cardiomegaly d/t LV dysfunction

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43
Q

What is mean gradient (when referencing valves)?

A

Difference in pressure between LV and Post-aortic valve

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44
Q

Which is worse valvular regurg? 1+ or 4+

A

4+

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45
Q

Decrease _______ with aortic regurg

A

Afterload

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46
Q

Dont give ____ ______ with aortic regurg

A

Beta Blockers

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47
Q

Dont give ____ ______ with aortic regurg

A

Beta Blockers

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48
Q

Sudden increase in LA pressure? What valve disease?

A

Mitral regurg

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49
Q

Main difference in acute vs chronic MR?

A

Acute - increase LA pressure

chronic - LA enlargement

See slide 73 on PP

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50
Q

HTN, AS, IHSS, LVH can all lead to what?

A

Concentric hypertrophy

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51
Q

With concentric hypertrophy, what 2 things lead to decreased supply?

A

-arteries in endocardium are compressed
-decrease CO

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52
Q

2 ways to increase supply w/ concentric hypertrophy?

A

-decrease HR
-maintain volume

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53
Q

If you decrease SVR with concentric hypertrophy, you can decrease filling of ______ arteries

A

coronary arteries

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54
Q

Eccentric hypertrophy = _______ LV

A

dilated

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55
Q

Give ______ drugs w/ eccentric hypertrophy

Which one?

Why?

A

inotropic drugs

Milronone

Doesn’t increase HR (and vasodilates)

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56
Q

Should you increase or decrease SVR w/ eccentric hypertrophy?

A

decrease

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57
Q

HOCM pts commonly die of __________

A

Arrhymias (Vfib/Vtach)

58
Q

Hypertrophic sub aortic stenosis is a _______ stenosis

A

dynamic

59
Q

Should decrease _______ with HOCM

A

contractility

60
Q

What 2 drugs are our friends with HOCM?

A

Beta blockers
Ca+ channel blockers

61
Q

What is common with athletes? (increased contractility)

A

HOCM

62
Q

What primary causes HOCM? (aside from contractility)

A

Hypertrophy of intraventricular septum

63
Q

Tx. for HOCM?

A

Septal ablations

64
Q

Need volume w/ HOCM?

A

Yes

65
Q

With decreased BP w/ HOCM, dont use _______ drugs. Use _____ and _______

A

Inotropic drugs

Neo & fluids

66
Q

Where is the aortic area?

A

2nd right intercostal space

67
Q

Where is the pulmonic area?

A

2nd left intercostal space

68
Q

Where is Erb’s point?

A

3rd left intercostal space, left sternal border

69
Q

Where is tricuspid area?

A

4th left intercostal space, left lower sternal border

70
Q

Where is mitral area?

A

5th left intercostal space, midclavicular line

71
Q

What murmur?

Second parasternal interspaces
Midsystolic

A

Aortic stenosis

72
Q

What murmur?

Third and fourth parasternal interspaces
Holodiastolic

A

Aortic insufficiency

73
Q

What murmur?

Apex
Mid-diastolic

A

Mitral stenosis

74
Q

What murmur?

Apex
Holosystolic

A

Mitral regurgitation

75
Q

What murmur?

Apex
Late systolic

A

Mitral valve prolapse

76
Q

Pneumonic for Valve area locations (from left to right, top to bottom)

A

All
People
Enjoy
Time
Magazine

77
Q

The _____ maneuver will decrease intensity of AS murmur

A

valsalva

78
Q

W/ Class I ACC/AHA valvular disease, symptomatic and no prior ______, then they need an _____

A

ECHO
ECHO

79
Q

Class IIa ACC/AHA valve disease - if ______ ok to go with surgery

A

non-symptomatic

80
Q

Dont do _______ ______ ________ __________ w/ class IIb ACC/AHA valve disease

A

percutaneous mitral balloon commissurotomy

81
Q

SA node bpm

A

60-100

82
Q

SA conduction speed through atrium

A

1.5

83
Q

AV node delay time

A

.15 second delay

84
Q

Speed of conduction at AV node

A

.05 m/sec

85
Q

Bundles speed of conduction

A

2 m/sec

86
Q

V escape rhythm bpm

A

20-40

87
Q

Av node bpm

A

40-60

88
Q

What is a bundle branch block?

A

Ventricles are depolarized at different times

89
Q

Pacemaker cell resting Vm

A

-70 mV

90
Q

Ventricular myocyte resting Vm

A

-90 mV

91
Q

What 4 ions responsible for action potential?

A

Na, K, Cl, Ca

92
Q

PVC is an _________ arrhythmia

A

ventricular

93
Q

Increased sympathetic activity usually causes what arrhythmia?

A

SVT

94
Q

BiV pacemaker may not have ____ mode

A

Async mode

95
Q

Dont order pre-op ______ if pacer depend. No point

A

EKG

96
Q

Detsky Modified Cardiac risk index 2 worst things

A

-Critical AS
-Class 4 Angina

97
Q

With DM pts, always check _____

A

Hbg A1C

98
Q

Most detailed cardiac assessment tool

A

NSQIP MI/Cardiac Arrest Risk Calculator (MICA)

99
Q

Functional capacity = ______ ________

A

cardiac reserve

100
Q

You want MET > ____ before surgery

A

MET > 4

101
Q

MET = ______ _________

A

Metabolic equivalents

102
Q

Highest surgical risk procedures (list a few)

A

Emergency surgery
Aortic
Vascular
Prolonged Procedures with fluid shifts
Total hip replacements

103
Q

Emergency neurohormone resembling atrial natriuretic peptide but synthesized primarily in the ventricles

Secreted in response to increased ventricular volume, pressure overload, or increased wall tension

Can be used in diagnosis of CHF; values rise and fall in response to exacerbation and resolution of CHF

Recommended according to the ACC/AHA Guidelines for Mgmt of HF

A

B-type Natriuretic Peptide (BNP)

104
Q

BNP <100

A

Normal

105
Q

BNP 100-300

A

HF present

106
Q

BNP 300-600

A

Mild HF

107
Q

BNP 600-900

A

Moderate HF

108
Q

BNP >900

A

Severe HF

109
Q

Marker for inflammation produced in the liver and smooth muscle cells
risk of atherothrombosis
May predict MI, CVA, PVD, sudden cardiac death
Information independent of other risk factors
Acute care
predict early and late mortality in acute ischemia
useful in chest pain mgmt with negative troponin levels

A

C-reactive protein

110
Q

Very sensitive and specific indicators of damage to the myocardium
Differentiate between unstable angina or MI in patients with chest pain or ACS. can also occur in patients with coronary vasospasm
Marker of all heart muscle damage, not just MI

A

Troponin

111
Q

ACC/AHA 2014 Recommendations for MI surveillance and Mgmt - Class I - Troponin and cardiac workup needed?

A

Yes

112
Q

ACC/AHA 2014 Recommendations for MI surveillance and Mgmt - Class III - Troponin and cardiac workup needed?

A

No

No benefit

113
Q

BNP currently 500. You see they have been 1000s in the past. You worried?

A

Nope

114
Q

ACC/AHA classes (this is true for all types). Class I = tx or testing needed?

Class III = tx or testing needed?

A

Class I = needed

Class III = not indicated

*this is true for all classification types under ACC/AHA

115
Q

ST depression and t wave inversion – abnormality of ___________

A

repolarization

116
Q

Least invasive, most cost-effective method of detecting ischemia

A

Exercise electrocardiography

117
Q

With the evaluation of LV fx, increased number of abnormal segments = _______ risk

A

increased risk

118
Q

You MUST inform patients of their _____

A

risks/informed consent

119
Q

You MUST document that you informed patients of their ______

A

risks/informed consent

120
Q

Cardiac patients must be _______ treated for hemodynamic changes

A

aggressively treated

121
Q

Assess ejection fraction and valvular function

Limited predictive value - failure to detect all IHD

A

Resting ECHO

122
Q

If heart is taking up more than ____ of the chest on an x-ray then there is concern

A

1/2

123
Q

Kerley-B lines (pulmonary vascular markings) = _______ ______

A

pulmonary edema

124
Q

Type of ECHO:

Can assess static function and/or dynamic function
Hibernating or stunned myocardium
High sensitivity and specificity for perioperative cardiac death and MI
Should not be used for patients with severe arrhythmias, significant hypertension, large thrombus-laden aortic aneurysms, or hypotension

A

Dobutamine stress ECHO

125
Q

A new _BB block does not go to OR

A

LBB block

Must be evaluated

126
Q

_____ pattern on EKG doesn’t not go to OR

A

Strain pattern

127
Q

EKG for low risk surgery?

A

No

128
Q

Low positive predictive value but high negative predictive value. What does this mean?

What is an example of this with cardiac workup?

A

Won’t tell us that they have a certain problem but will tell us that they dont

ex. exercise electrocardiography

129
Q

Dyskinesia

A

when the ventricle muscle contracts it “flops opposite ways”

130
Q

Hypokinesia

A

Ventricle doesn’t contract much

131
Q

Akinesia

A

Ventricle doesn’t contract at all

132
Q

_______ ECHO is not useful to predict abnormalities under OR stress

A

resting

133
Q

this type ECHO has high sensitivity and specificity for perioperative cardiac death and MI

A

Dobutamine stress echo

134
Q

Dont do ________ _____ ECHO for AS pts

A

Dobutamine stress echo

135
Q

Thalium-201 or cardiolyte are the ______ for exercise nuclear imaging

A

markers

136
Q

Agents to use to increase demand during Pharmacologic Stress Thallium Imaging?

A

Coronary vasodilators - Adenosine and Persantine (dipridamole)

Inotropes (increase demand)

137
Q

Would you rather have a fixed or reversible cardiac defect?

A

Fixed

138
Q

Gold Standard for defining coronary anatomy

A

Cardiac Angiography

139
Q

Know PP slide 129 normal PA cath values

A

Know slide 129 on PP

140
Q

Best monitor for looking at the heart on the spot in the Or

A

TEE

141
Q

Look at PP slide 135 for a few considerations w/ anesthetic techniques regarding different surgeries

A

PP slide 135

AFN Health Assessment (12 decks)

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