Cardiology Flashcards
The determinate of myocardial consumption from most important to least are …
Contractility > HR > afterload > preload
Can preload be measured by end-diastolic volume, how about end-diastolic pressure (LVEDP)?
You can measure preload from end diastolic pressure (LVEDP)only in patients with good left ventricular compliance.
So in elderly, you cannot measure preload from LVEDP because their LV compliance is reduced
LV coronary perfusion occur during … and depends on …
Diastolic period and depends on Aortic diastolic pressure
LV perfusion = Aortic diastolic pressure -LVEDP
RV perfusion occur during … and depends on …
Diastole & systolic period
Depends on MAP
SA node supplied by … and AV node by …
Both by RCA (60% in people for SA node and 90% for AV node)
Heart block seen with … occlusion
RCA
R dominant coronary circulation is when …
PDA arises from RCA
Left dominant coronary circulation is when
PDA arises from LCA
ANP released in response to …
Atrial wall stretch due to increase in L atrial volume
Angio I converted to Angio II in
Lungs
When hypotension and bradycardia and coronary dilatation occur as reflex 2/2 LV ischemia, reflex called …
Bezold-Jarisch Reflex
Cushing Reflex is
Hypertension & bradycardia due to increased ICP
What’s reflex named when stretching pulm stretch receptors due to inflation of lung results into inhibition of inspiration & allows expiration
Herring-Breuer Reflex
Frank-Starling Curve is relationship between
SV/CO (on left)
Preload/LVEDV (bottom)
Frank-Starling curve moves down in
Decrease preload, contractility or increased afterload
Frank-Starling curve moves up in
Increased preload or Contractility. And decreasing afterload
Phenylephrine vs Milrinone on Frank-Starling curve
Phenylephrine: “dose dependent “ curve up -> low doses, increases central blood volume
Curve down -> increases afterload with high doses
Milrinone -> increases Contractility & decreases afterload -> curve up
Absent A wave in …
Afib
A wave: Atrial contraction
Large A wave due to …
Complete heart block
Tricuspid stenosis
Pulm HTN
Large V wave in …
Tricuspid regurgitate
V: atrial Villing
Steep Y decent in …
Constructive pericarditis
Y: passive BF from atria to ventricular resulting into decrease RA pressure/decent of Y I ave on CVP trace
Absent or attenuated Y decent in
Cardiac tamponade
Tricuspid stenosis
CVP trace in Afib
Absent a wave
CVP trace in junctional rhythm and complete heart block
Cannon a wave (large a wave)
Large C-V wave or fused C and V wave seen in
Tricuspid regurgitate
Cannon a wave seen in
AV dissociation
Absent a wave, prominent c wave seen in
Afib
Tall systolic c-v wave seen in
Tricuspid regurgitate
Tall a wave, attenuation of Y decent seen in
Tricuspid stenosis
Tall a wave, steep x, decent Y seen in
Constructive pericarditis
Dominant x descent, attenuated y descent seen in
Pericardial tamponade
What trace on Pulm artery suggests MI?
Large V wave which is due to mitral regurgitate
Cardiac cycle phase occur during P wave is …
Ventricular filling
Cardiac cycle occurs during RS wave on ECG is
Isovolumetric contraction
Cardiac cycle phase occur during T wave on ECG is …
Ventricular ejection
HD goal in IHSS
Increase preload & afterload
Decrease HR, Contractility
HD goal in MR & AR
Mild tachycardia
Mild reduction in afterload
HD goal in cardiac tamponade
Fast: increase HR
Full: increase preload
Tight: increase afterload
Slow rising pulse with late systolic peak is a character for ….
AS
This is pulses parvis et tarsus
Rapid upstroke & rapid decent pulse “collapsing pulse” “ water hammer pulse”
AR
Alternate strong & weak pulse “pulses alternate”
LV failure
Combination of slow rising & collapsing pulse “pulses bisfernance”
Combined AS & AR
Mid systolic obstruction “spike & dome pulse”
HCM
great than 10 mmHg drop in BP during inspiration “pulses paradoxes”
sever Acute Asthma or cardiac tamponade
Area of auscultation MV TV PV AV
M: Left to nipple intercostal
T: Left lower eternal border
P: 2nd left intercostal left to sternum
A: 2nd right intercostal right to sternum
Pansystolic murmur anterior lower eternal border
VSD
Continuous machinery murmur (below left clavicle)
PDA
Murmur posterior interscapular
Coartictation of aorta
Mid systolic murmur
MS
Pansystolic murmur
MR
Ejection systolic murmur
AS
Early diastolic murmur
AR
Angio II is … vasoconstriction
Direct
Vasopressor ineffective in cocaine abuser is
Ephedrine
Due to catecholamine depletion
In CHF, beta adrenergic receptors are … regulated
Down
Cardiac RFs for patients undergoing non cardiac Surgery are
Recent MI
Valvular diseases
Uncompensated HF
Causes for PCWP > LVEDP
MA
Left atrial myxoma
Elevated alveolar pressure
Pulm venous obstruction
Cause for LVEDP > PCWP
AR
Carotid sinus reflex during carotid endarterectomy causes … and can be blocked by …
Hypotension + bradycardia
Local anesthetics at carotid bifurcation
Afferent: glossy pharyngeal
Efferent: vagus
Baroreceptors denervation after b/l carotid endarterectomy results into
Hypertension + tachycardia
Chemoreceptors denervation leads to decreases hypoxia drive of respiratory
Neuromonitors used during carotid endarterectomy are
Awake patient Carotid stump pressure > 60 mmHg Cerebral oximetry SSEP EEG Trans cranial Doppler flow of meninges artery
The common cause of ischemia during carotid endarterectomy is
Embolism
Autonomic hyper reflex is occur in … and manifests as … and commonly seen … after insult. a drug to avoid is …
Management is …
Prevention…
Spinal cord transaction at T7 or above
Hypertension + bradycardia. Profuse sweating, flushing (vasodilation) above lesion level, blanching + vasoconstriction below level of lesion
Common 6 months to 2 years following injury
Avoid succinylcholine
Na Nitroprusside, nitroglycerin (2nd choice), alpha blocker less effective. Avoid beta blockers alone.
Prevention: GA or spinal.
Acute spinal cord transaction immediate manifestation
Spinal shock and lasts hours to one month.
Hypotension (due to increased venous capacitance) and flaccid paralysis.
Automatic hyperreflexia occurs 6 months - 2 years following insult
During isovolumic hemodilusion, tissue perfusion increases due to
Decreases in viscosity
During aortic cross clamp, afterload … which translate into … and … hence it increases risk for MI in susceptible patients
Increases afterload -> intraventricular pressure, myocardial wall tension, and myocardial O2 consumption
The commonest cause of decreased renal perfusion in aortic cross clamp is …
Hypovolemia
The best measure for renal protection during infra-renal aortic cross clamp is …
Maintenance of intravascular volume status
If sever hypotension associated with ECG ischemic changes occur after release of aortic cross clamp occur, best immediate course is to …
Reapply the cross clamp
ECG changes in
HyperCa
HypoCa
Short QT interval
Long QT interval
Management of prolonged QT interval + torsades is ….
Mg
WPW syndrome on ECG
Short PR < 0.12
Delta wave
Mgmt of WPW syndrome
Vagal maneuvers Adenosine Procainamide Esmolol Cardio version
CI drugs for WPW syndrome
Digoxin
Verapamil
What’s % of CO dependent on atrial kick in AS patients?
40%
SBE ppx
1) prosthetic material used for valve.
2) previous IE
3) un-repaired cynotic CHD.
4) cardiac palliative shunts & conduit
5) valvulopathy in transplanted heart
6) 2 conditions in repaired CHD
- repaired CHD + residual defects at the site or adjacent to prosthetic patch/device
- within first 6 month after procedure if prosthetic material or device implanted.
Un-repaired cynotic CHD receive SBE ppx, but repaired once only gets them in 2 conditions
2 conditions in repaired CHD
- repaired CHD + residual defects at the site or adjacent to prosthetic patch/device
- within first 6 month after procedure if prosthetic material or device implanted.
Because endothelialization prosthetic material occurs > 6 months, and if defect adjacent to material it inhibits
Indications for permanent pacing
- Symptomatic bradycardia
- Symptomatic second degree block
- Asymptomatic mobitz 2 with wide QRS
- Post Anterior MI (3rd, 2nd degree block + bundle branch block).
- 3rd degree block
- refractory SVT
Indications for AICD
VF/VT Long QT HOCM + VF/VT Post MI + EF <30% Dilated CMP
Pacemaker Letters Description I -> II -> III -> IV -> V ->
I -> Chamber paced (O,A,V,D) II -> Chamber sensed (O,A,V,D) III -> Response to sensing (O,T,I,D) IV -> Programmability, rate modulation (O,R) V -> Antitachycardia function (P,S,D)
IV pacing: Rate Modulation
Vibration sensor Motion sensor Minute Ventilation QT interval RV pressure
V pacing: Multisite sensing
Atrial multidite pacing for AF
Ventricular multisite pacing for CMP
Fixed rate/asynchronous mode pacing letters are
VOO, AOO, DOO
whats type of pacemaker used for AV block + atrial bradycardia
DVI
Dual champers paced
Ventricular sensor
Inhibitor if sensed
Indications for reprogramming DDD pacemaker?
Pacer dependence Rate responsiveness Dilated CMP, HOCM. Pediatrics Procedures close to the pacemaker
the commonest cause of seening slower rate than whats pacemaker set at is …
battery failure
Contraindication for AICD
MRI
is it safe to undergo ECT, synchronized cardioversion, or radiofrequency ablation with patients that have AICD?
Yes they are not contraindicated.
deactivate AICD with each treatment the reactive afterwards
methods to reduce trans-thoracic resistance during external defibrillation
- Large paddle
- Application of pressure on paddles.
- Conductive gel
- Shave hairy chest
- Biphasic shock
benefit of using Epi in anaphylaxis is …
it stabilize mast cell membrane
benefit of using Epi in cardiac arrest or Vfib is …
its vasoconstriction & improve cerebral & myocardial BF. it also reduced VFib threshold & cellular refractory period which stabilizes the fibrillation in V-fib
The most sensitive indicator for LV myocardial ischemia is
wall motion abnormalities on TEE
The correct placement of lead 5 is
Left 5th intercostal space in anterior axillary line.
ST changes are significant if it occur
1 mm for depression
2 mm for elevation
when occurs 80 m sec. after J point (QRS-ST junction)
Ischemic changes in II, III, AVF, and AV block
Inferior wall -> RCA
Ischemic changes in I, AVL
Lateral wall -> Circumflex Artery
V3-V6 ischemic changes
Anterioseptal wall -> LAD
New apical systolic murmur in AS patient means
MR 2/2 MI
The definition of Pulm Htn
- PA systolic > 35 mm/Hg
- Resting PA mean > 25 mm/Hg
- PA mean > 30 mmHg during exercise
next step when heparin resistance occur during CPB (target ACT not achived)?
FFP as a source of antithrombin III
is remote h/o HIT CI for heprain use for CBP?
no, however recent HIT is CI and warrent use of Bivalirudin
The best initial TEE view to detect MI after coming off Bypass is …
transgastric short axis view (all walls are seen with this view)
if + ischemia then do mid-esophageal view.
The most difficult area to see on TEE is … and therefore … is likely to be missed
arch of aorta
intimal tear in aorta
CI to TEE
- Esophageal obstruction
- GI perforation.
- Active GI bleeding.
- Esophageal varices
- Esophagectomy/esophagogastrectomy
- Tracheoesophageal fistula
The most common cause of acute LV dilatation after aortic cross clamp during CPB is
AR
the commonest causes for hypotention at initiation of CPB with adequate BF & venous return are
vasodilation or hemodilution
indications for retrograde cardioplegia
- AR
- type A dissection
- sever left main stenosis
solubility of gas during hypothermia …. therefore pH would …
increases -> gas in the gaseous phase decreases -> partial pressure of gas decreases -> PaO2, PaCO2 decreases and pH increase
elevated CO2 on pump indicates
inadequate ventilation, so increase fresh gas flow
Type 1 protamine rxn is … and caused by … manifests as …. treated with …
Anaphlactoid rxn
1) rapid administration
2) first time exposure
3) IgG mediates & complement activation.
systemic hypotension
fluids & vasopressors
Type 2 protamine rxn is … and caused by … manifests as …. treated with …
Anaphlactic rxn
1) prior exposure.
2) IgE mediated & complement
systemic hypotention
fluids & vasopressors
Type 3 protamine rxn is … and caused by … manifests as …. treated with …
Thromboxane release from plt & macrphages
systemic hypotention + pulm Htn
Reheparinse and go on CPB
the cause of pulm Htn in type 3 protamine rxn is ….
Thromboxane release from plt
also seen in pre-eclampsia
during rewarming following cpb, …. temp lags behinde other core temps
rectal temp
decreased O@ sat when coming off bypass with other parameters within normal range is possibly due to
shivering during rewarming
give NMB
pH stat
- During hypothermia, PaCO2 decreases due to increased solubility.
- pH stat is when maintaining CO2 at 40 mmHg by reducing sweep oxygenation or less commonly adding CO2
pH or Alpha recommended for adults?
Alpha = Adults
better neurological outcome
Which to use pH or alpha stat for pediatric or deep hypothermia?
pH stat increases CO2 improves CBF, uncopules CBP/O2 consumption (neuroprotective for infants on CPB).
pH stat produces more homogenous cooling, less O2 consumption, and better metabolic recovery than alpha.
now the trend is using pH stat during cooling and alpha stat during rewarming, if deep hypothermia is used
CI tointra-aortic pump
AR
b/l sever aorto-occlusive disease
IABP is inflated synchronous to
dicrotic notch of ABP wave
IABP increases … and decreases …
DBP
SBP, myocardial O2 consumption, afterload
low CI, hypotension, and equalization of CVP with PCWP after CABG, suspect …
Cardiac tamponade
mortality rate after coronary revascularization is … and increased to … in ARF
0.9%
63%
most important predictor of hospital mortality in CABG patients are
number of inotropy & transfusion during procedure and immediate postop.
the resting heart rate in denervated transplanted heart is
high around 100
Lack of vagal tone will result in baseline rate of 90-100.
denervated transplanted heart respond to drugs that
has direct effect on heart (epi, norepi, and isoproterenol)
denervated transplanted heart dose not respond to drugs that
alter nodal function or HR indirectly such as antimuscuranics, anticholinergics, pancuronium, digoxin.
denervated transplanted heart dose not respond to or dose respond to hypovolemia, hypotension, or laryngoscopy?
Transplanted hearts have no baseline parasympathetic innervation and thus don’t have the normal tachycardia and increased contractility response to hypotension/hypovolemia. Reflex venous contriction response to hypotension still exists.
dose not respond to physiological reflexes to hypovolemia, vasodilation, carotid sinus massage, laryngoscopy or exercise.
Vagal bradycardic reflexes will also be absent (laryngoscopy, hypertension, carotid sinus massage).
What agent of choice to treat bradycardia in heart transplanted patients?
The transplanted heart will not be able to respond to drugs that act by blocking the parasympathetic system because these connections were severed during the transplant. Therefore, treating bradycardia would have to be done with agents such as isoproterenol, glucagon, epinephrine, norepinephrine (drugs that have a direct effect on the heart). Isoproterenol is most commonly used for increasing heart rate in cardiac transplant recipients. Epinephrine/Norepinephrine may have exaggerated beta mimetic effects on the heart rate because the increase in blood pressure will not lead to a reflex slowing of the heart rate via the baroreceptor reflex (i.e., efferent vagus nerve). Implanted mechanical pacemakers work normally in heart transplant recipients since the cardiac leads are placed directly into myocardium.
About 25% of patients will develop a bradycardia that will require implantation of a permanent pacemaker.
SVO2 increases in
Sepsis & Cyanide toxicity
SVR =
MAP-CVP/CO x80
PVR =
PAP-PCWP/CO x80
The cardiovascular compensation for sever anemia is
Increased CO
RAAS system activated in
Hypovolemia
CVS physiological changes in elderly are
- increased SBP
- unchanged/decreased DBP
- Decreased LV compliance
- increased incidence of diastolic dysfunction
- decreased arterial compliance -> increases afterload.
- increased fibrosis of the conduction system -> increases incidence of arrhythmias
- decreased baroreceptors reflexes -> decreased response t o anticholinergics.
the commonest cause of diastolic dysfunction/impaired diastolic relaxation is
increased afterload with cocentric ventricular hypertrophy resulting into CHF
Complications of TAVR?
15% AV block during valve deployment and positioning.
11% Dissection, perforation or thrombosis of ileofemoral vessels
Acute coronary occlusion after deployment: ST changes, LV failure
What TEE view the SVC and IVC can be seen?
Bicaval 90 degree
