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Apex Review > Cardio > Flashcards

Cardio Flashcards

1
Q

Duration to wait until elective surgery for Angioplasty no stent

A

2 - 4 weeks

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2
Q

Duration to wait until elective surgery Bare metal Stent and CABG

A

6 weeks minimum 12 weeks prefered

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3
Q

Duration to wait until elective surgery Drug eluding stent

A

1 year

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4
Q

Duration to wait until elective surgery CABG

A

6 weeks minimum 12 weeks preferred

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5
Q

What’s the best treatment for stent thrombosis ?

A

Percutaneous coronary intervention. Best outcome achieve if blood flow restored in less than 90 min.

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6
Q

Compliance of ventricle is decreased by:

A
  1. Edad mas de 60 años 2. Ischemia 3. Pressure overload hypertrophy ( HTN or aortic stenosis) 4. Hypertrophic obstructive cardiomyopathy 5. Pericardial pressure
  • Clinical take away here is that higher filling pressure are required to prime the ventricle
  • Preservation of NSR and atrial kick are critically important to maintain priming function
  • elevated filling pressures put patients at higher risk of pulmonary edema
  • for any condition that reduces ventricular compliance , the CVP and PAOP may overstimate LVEDV
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7
Q

Compliance of ventricle is increased by:

A

Conditions that dilate the heart: Chronic aortic insufficiency Dilated cardiomyopathy

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8
Q

What is the initial elevation, peak elevation of CKMB and when does it return to baseline?

A

Initial elevation is 3 - 12 hrs Peak elevation is 24 hrs Return ti base line 48 - 72 hrs

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9
Q

What is the initial elevation, peak elevation of Troponin-I and when does it return to baseline?

A

Initial elevation is 3-12 hrs Peak elevation is 24 hrs Return to base line 5-10 days

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10
Q

What is the initial elevation, peak elevation of Troponin T and when does it return to baseline?

A

Initial elevation is 3-12 hrs Peak elevation 12-48 hrs Return to base line is 5-14 days

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11
Q

What are the Risk factors for cardiovascular morbidity and Mortality?

A
  1. High risk surgery
  2. History of ischemic heart disease ( unstable angina confers the greatest risk of perioperative MI)
  3. History of CHF
  4. History of cerebrovascular disease
  5. Diabetes mellitus
  6. Serum Creatinine >2 md /dl (Normal 0.7-1.5mg/dl)
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12
Q

Define unstable angina

A

Unstable angina is definced as

  1. angina at rest
  2. new onset angina (<2 months)
  3. increasing symptoms ( intensity, frequency, duration) duration exceeds 30 minutes
  4. symptoms have become less responsive to medical therapy.
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13
Q

Risk of having perioperative MI in Patients with previous MI

When is the greatest highest risk of reinfartion?

A
  1. General Population= 0.3%
  2. MI >6 moths = 6%
  3. MI 3-6 months= 15%
  4. MI<3 months= 30 %

The highest risk of reinfartion is greatest within 30 days of an acute MI

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14
Q

What is the ACC/AHA guideline for recent MI?

A

The ACC/AHA guidelines recommend a minimum of 4 - 6 weeks bedore considering elective surgery in a patient with a recent MI.

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15
Q

What are the cardiovascular risk for surgical procedures?

A
  1. High Risk (>5%)
    • Emergency surgery ( more in elderly)
    • Open aortic surgery
    • Peripheral vascular surgery
    • Long surgical procedure with significant volume shift and /or blood loss.
  2. Intermediate risk(1-5%)
    • Carotid endarterectomy
    • Head and neck surgery
    • Intrathorasic or intraperitoneal surgery
    • Orthopedic surgery
    • Prostate surgery
  3. Low Risk(<1%)
    • Endoscopic procedure
    • cataract surgery
    • superficial procedure
    • Breast surgery
    • ambulatory procedure
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16
Q

What’s the modified NY association functional classification of Heart Failure?

A
  1. Class I: Assyntomatic
  2. ClassII: Symptomatic with moderate activity
  3. Class III: Symptomatic with mild activity
  4. Class IV: symptomatic at rest
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17
Q

What Factors that reduce Oxygen Delivery or Supply ?

A
  1. Decreases CPP
    • Tachycardia
    • increased EDP
    • decreassed AoDP
    • decreased vessel diameter
  2. Decreased CaO2
    • Hypoxemia
    • Anemia
  3. Decreased Oxygen extracion
    • deceased P50
    • Decreased capillary Desnsity
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18
Q

What factors increase O2 demand?

A
  1. Tachycardia
  2. hypertension
  3. increase wall tension
  4. increase EDV
  5. Increased afterload
  6. SNS stimulation
  7. Increased contractility
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19
Q

What is the best lead to monitor intraoperative ST changes?

A
  • Normal EKG or no EKG on file : V3 > V4 > V5 > III > AVF
  • Abnormal EKG: monitor region at freatest risk of ischemia

In patient with CAD

  • 5 cable EKG: V3, AVF and MCL5 or III
  • 3 cable EKG: AVF and MCL5

Lead II is best for monitoring for dyssrhythmiaswith a narrow QRS where P wave analysis is critical for DX ( junctional, a-fib or a-flutter)

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20
Q

In how many hours doesmust posoperative miocaldial infartion occurs?

A

within 48 hrs after surgery

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21
Q

How to treat myocardial ischemia?

A
  1. Increased O2 demand
    • increased HR- use beta blocker to HR <80
    • increased BP- increase depth of anesthesia or use a vasodilator
    • Increased PAOP- nitroglycerine
  2. Decreased O2 Demand
    • decreases HR- Anticholinergic, pacing
    • decreased BP- vasoconstrictor, decreased depth of anesthesia
    • increased PAOP- Nitroglycerine, inotrope
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22
Q

What’s the hallmark of Systolic heart failure?

What causes Systolic Heart Failure?

A

in systolic heart failure the ventricle doesn’t empty well

The hallmark is

  1. decreased ejection fraction
  2. increased end-diastolic volume ( volume overload commonly caused systolic disfuction)
    • since heart can’t squeeze well a greater volume will stay in the ventricle after each contraction
    • less oxygen rich blood is delivered to the periphery
    • the arterial-venous oxygen content difference is increased
    • Compensatory mechanism: Increases SNS, increases RAAS, increases Preload

Is caused by:

  • Myocardial ISchemia
  • Valve insufficiency
  • Dilated cadiomyopathy
  • Eccentric
  • Increased Compliance
23
Q

What happens during diastolic failure ?

What are the characteristics?

What causes diastolic failure?

A

Diastolic failure occurs when the heart is unable to relax and accept an incoming volume because ventricular compliance is reduced.

Characteristics:

  • symptomatic heart failure with a normal ejection fraction

Contractility is generally preserve until late stage of disease.

Causes:

  • Myocardial Ischemia
  • Valve stenosis
  • Hypertension
  • Hyperthophic cardiomaopathy
  • Cor pulmonale
  • Obesity
  • increased compliance of ventricle
24
Q

What is cardiac remodeling and what medication reversed it?

A

is the ability of the heart to change it’s size, shape and function in an attemps to preserve cardiac output.

Cardiac remodeling can be reverse by:

  • ACE inhibitors (pril)
  • Spironolactone
25
Q

Cardiovascular effect of systolic and diastolic failure and anesthetic considerations.

A

See pictures

26
Q

What percentage of population in the USA is affected by hypertension?

A

30%

27
Q

What are some complication of hypertension?

A
  1. Left ventricular hyperthrophy
  2. ischemic heart disease
  3. CHF
  4. arterial aneurysm
  5. stroke
  6. end-stage renal disease
28
Q

How does hypertension causes CHF?

A

see picture

29
Q

How to dx hypertension?

What’s their classification?

A

hypertension is diagnose when BP exceeds 140/90 mmgh. to confirm the dx blood pressure should be measured on two separate occasions no sooner than 1-2 weeks aparts

Primary classification- no causa identificada 95% of HTN

secondary classification causa identificada 5% of HTN

30
Q

What is the cause of primary HTN?

A
  1. chronic vasoconstrction increases renin release - increases angiotensin I- increases angiotensin II and aldosterone increases sodium and water retention.
  2. SNS overactivity- chronic vasoconstriction - increases SVR
  3. Vasodilator deficiency ( decreases NOand prostaglandins) - Increases SVR
  4. Collagen and metalloproteinase deposist in the arterial intima - increases vascular stiffness - increases SVR
  5. Diet ( increases Na intake and or decreases K and CA intake)

Blood pressure is regulated by feedback networks consisting of the SNS (baroreceptors) , RAAS and Vasopressin.

HTN occurs by increase CO or SVR - elevated SVR is almost always the cause.

31
Q

What is the most common cause of secondary HTN?

What are other causes?

A

the most common cause of secondary htn is renal artery stenosis. A narrowed renal artery delivers less blood to affected kidney. in attemps to increase GFR the kidney activates RAAS system.

other causes see pictures.

32
Q

Which calcium channel blocker should I used for control of HR?

A

Verapamil and dialtizem are better choice to reduce HR in patient with tachycardia, Atrial fribilation or a-flutter

33
Q

Which calcium channel blocker should I used for control of contractility

A
  • Do you nedd to preserve contractility when you’re reducing heart rate? in the patient with a reduced EF, this is probably a wise idea.
  • CCM impair contractility in the following order highest to lowest: verapamil > nifedipine > dialtizem > nicardipine
  • in patient with decreased contractility, dialtiazem is a better choice than verapamil
34
Q

Which calcium channel blocker should I used for control of Vascular tone

A

Nifedipine, amlodipine, and nicardipine are vasodilators and are best ised in the tretment of hypertension from elevated SVR.

Nicardipine is useful as a coronay antispasmodic.

35
Q

What is the heart basal oxygen consumption?

A

8-10ml/O2/min

36
Q

What are the components and effects on Myocardial oxygen consumtion?

A

Heart rate- pressure work>Contractility>Wall stress> Volume work

37
Q

What are the signs of constrictive pericarditis?

A
  1. Kussmual sign
  2. Pulsus Paradoxus
  3. Atrial dysrhytmias
  4. Pericardial Knock
  5. Increased venous pressure
38
Q

What are the sign of aucte pericarditis?

A
  1. Acute chest pain
  2. Fever
  3. Pericardial friction rub
  4. ST elevation
39
Q

What is Kussmul sign?

A

Is a paradoxical rise in jugular venous pressure during inspiration.

It’s cause by restriction in RV filling, and the high right-sided heart pressure is reflected back to the jugular vein. On the CVP wave form the x and y descent are often exagerated

40
Q

Which conditions are assciated with high risk of developing cardiac endocarditis?

A
  • History of inefective endocarditis
  • Prosthetic heart valve
  • heaert transplant with valvuloplasty
  • unrepair cyanotic congenital heart disease
  • repair congenital heart disease if the repair is <6 months
  • repair congenital heart disease with residual defects that have impared endothelializationat the graft site.
41
Q

A patient with a prostetic heart valve what procedures you have to give antibiotics prophilacxys?

A
  1. Dental procedures involving gingival manipulation and or damage to mucosa lining
  2. Respiratory procedures that perforate the mucosal linin with inscicion or biopsy
  3. Biopsy of inefective lesion on the skin or muscle
42
Q

What are the different names for idiopathic hyperthrophic subartic stenosis?

A
  1. Obstructive hyperthrophic cardiomiopathy
  2. Hyperthrophic obstructive cardiomiopathy
  3. Idiopathic hypertrophic subaortic stenosis
  4. Asymmetrical septal hypertrophy
43
Q

What 4 conditions increase the risk of LVOT obstruction?

A
  1. Condition that decrease preload
    1. Vasodilators
    2. Neuraxial anesthesia
    3. Hypovolemia
    4. POstural changes
    5. Positive pressure ventilation
    6. Valsalva maneuver
  2. Conditions that decrease afterload
    1. VAsodilator
    2. Neuraxial Anesthesia
    3. Oxytocin
  3. Conditions that increase contractility
    1. beta agonist
    2. digoxin
    3. light anesthesia
  4. Conditions that increase HR
    1. B block
    2. Ketamine
    3. Pancuronium
    4. Desflurane
    5. light anesthesia
    6. Histamine releasing drug
      5.
44
Q

Describe the difference between Beck’s syndrome and Beck’s Triad

A
  1. Becks Syndrome- is the anterior spinal syndrome
    1. Flaccid paralysis of lower extremities (impared motor tracks)
    2. Bowel and bladder dysfunction ( impair motor tracts)
    3. Loss of temperature and pain ( impaired spinothalamic tract)
    4. Touch and propioception ( Intact dorsal column)
  2. Becks Triad- ( hypotension, Jugular venous distention, Muffle heart sounds) occurs as a consequence of cardiac Tamponade
45
Q

What are the strategies used during thorasic cross clampping to protect spinal cord perfussion?

A
  1. CSF drainage- Csf shinting fron the brain towards the spinal column during clamping can exert excess pressure on the spinal cord. Drainin CSF improves spinal cord perfusion ( spinal cord perfusion=MAP - CSF pressure
  2. moderate hypothermia ( 30-32 C)
  3. Proximal hypertension during cross clamp ( MAP-100mmgh)
  4. Partial CPB ( left atrium to femoral artery)
  5. Drugs- corticosteroids, CCB and mannitol
46
Q

Factors that Distort CVP and PAOP pressure Tracings

A
47
Q

POtential causes of elevated CVP, PAP and PAOP

A
48
Q

Factors that alter the relationship amoung central cardiovascular pressures and volumes

A
49
Q

Kawasaki’s Disease

A
  1. Occurs primarly in children
  2. S/sx:
    1. fever
    2. vasculities
    3. red”strawberery” tounge
    4. conjutivitis
    5. inflammation of mucus membranes
    6. cervical lymphadenopathy
    7. swollen hands and feet
  3. Affects coronary arteries and medium size arteries
  4. At risk of coronary artery aneurysm and myocardial ischemia
  5. “Name game” Mucocutaneous lymph node syndrome
50
Q

Wedener’s Granulomastosis

A
  1. Necrotizing granulomas lead to vasculities ( imflammed arteries) in the airway, lungs, CNS, and kidneys
  2. Friable, necrotic tissue in the airway bleeds easuly. Tracheal granulomas reduce tracheal diameter. Be careful during airway management and downsize the endotracheal tube
  3. Lung granulomas can cause hypoxemia.
51
Q

Tromboangiitis Obliteration

A
  1. Inflammatory vasculitis that ultimately occludes the small and medium-sized arteries and veins in the extremities ( it obliterates the blood vessels. This leads to raynaud’s- like symptoms
  2. A cold environtment can impair perfusion, leading to ischemia of the affected extremities; maintainance of normo termia is critical. Be very careful with padding and positioning
  3. Smoking is the most common cause and smoking cessatoin is the best treatment
  4. Name game- Buerger’s disease
52
Q

Takayasu’s Arterities

A
  1. Occlusive disease of the proximal aorta and its main branches
  2. Name game- pulsless disease or occlusive thromboaortopathy or aortic arch syndrome
53
Q

symptoms of subclavian steal

A
  1. vertigo
  2. syncope
  3. hemiplegia
  4. blood pressure in the affected arm its lower than the contralateral arm
  5. Distal pulses may be diminish or absent

tx: subclavian endarterectomy

Apex Review (4 decks)

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