Cardiology Exam 1 Flashcards
1
Q
Systolic dysfunction what is going on with the EF, EDV, and contractility?
A
reduced EF
reduced contractility
increased EDF
2
Q
Diastolic dysfunction what is going on with the EF, EDV, and compliance?
A
preserved EF
reduced compliance
normal EDV
3
Q
Orthopnea
Paroxysmal nocturnal dyspnea
Pulmonary edema
describes what type of heart failure?
A
Left sided heart failure
4
Q
Hepatomegaly
JV distension
Peripheral edema
describes what type of heart failure?
A
Right sided heart failure
5
Q
Valvular stenosis causes pressure overload or volume overload?
A
pressure overload
6
Q
valvular regurgitation causes pressure overload or volume overload?
A
volume overload
7
Q
What causes increased afterload?
A
systemic hypertension
8
Q
Increased preload leads to symptoms of pulmonary vascular congestion
Symptoms would include what three things?
A
Dyspnea
Orthopnea – SOB when supine (gravity effect)
Paroxysmal nocturnal dyspnea, pulmonary edema
(all left sided failure issues)
9
Q
most common cause of left-sided heart failure is?
A
right sided heart failure
10
Q
COPD can cause which side of the heart to fail?
A
the right ventricle
11
Q
If COPD was to cause right sided heart failure what would happen to the pulmonary vascular resistance and right sided pressure?
A
increase in pulmonary vascular resistance, resulting in right-sided pressure overload
12
Q
Backward congestion symptoms would include?
A
Dyspnea , orthopnea, PND
JV distension (increased venous pressure)
Peripheral pitting edema
13
Q
Signs of CHF?
A
Tachycardia S3 (ventricular gallop) , S4 (atrial gallop) Rales Cardiomegaly Ascites Hepatic congestion (increased CVP)
14
Q
What is a normal BNP?
A
Less than 100 thus it is elevated (100-300) the heart is starting to fail.
15
Q
an echo can tell you what?
A
systolic and diastolic dysfunction
16
Q
what meds reduce afterload and improve survival?
A
ACE inhibitors or ATR blockers
17
Q
What meds treat diminished contractility?
A
Digoxin
Beta agonist – dopamine
Amrinone (PDE inhibitor)
18
Q
What do you have the beware of with digoxin?
A
Inhibit Na/K ATPase
BEWARE digoxin toxicity with hypokalemia (with diuretics) , elderly and renal insufficiency
19
Q
If you have digoxin toxicity what will you see on an EKG?
A
PVC’s
ST depression ‘ dig effect’
Paroxysmal atrial tachycardia with varying block
20
Q
Anesthesia concerns with CHF?
A
watch fluid status very carefully!
avoid nitrous oxide in sever CHF
arrhythmias are poorly tolerated
21
Q
Treatment of heart failure, what does ABCDE stand for?
A
ACE inhibitors Beta-blockers Calcium channel blockers Diuretics Endothelin receptor blockers leads to decrease pulmonary vascular resistance
vasodilation = endothelin receptor blocker.
22
Q
What is the major determinant of intravascular volume in the body?
A
Na+
23
Q
What is the most important hormone for controlling vascular volume?
A
aldosterone
24
Q
What two factors determine preload?
A
intravascular volume and venous tone
25
venous constriction leads to what?
high preload
26
stroke volume is determined by three factors?
preload
afterload
contractility
27
CO =?
Stroke volume x HR
28
Mean arterial pressure = ?
CO x SV
29
What is normal EF?
60-80%
30
EF = ?
stroke volume / end diastolic volume
31
EF is an index of ventricular contractility which is a measure of what function?
systolic function
32
What is normal SVR?
1200-1500 dynes/sec/cm-5
33
what is the major determinant of SVR?
Arterioles
34
SVR =?
MAP-CVP/CO X 80
35
What % of cardiac output goes towards coronary circulation?
5% = 250ml/min @ rest
36
When does maximum flow of blood occur to the coronary arteries?
during diastole
37
If you have diastolic dysfunction what blood supply can that interrupt?
coronary blood supply bc it occurs during diastole
38
Two ways to cause vasodilation in the heart vessels?
hypoxia and adenosine
39
What factors reduce coronary blood flow?
tachycardia
| aortic stenosis
40
When talking about the heart, increase in demand for oxygen must be met with?
increased blood flow bc the myocardium sucks all the oxygen from the arterial blood.
41
What are the two major determinants of flow to the heart?
LVEDP and HR
| supply vs demand
42
Most volatile anesthetics do what to the heart? (making them ideal for MI)
coronary vasodilators!
43
When is the right ventricle perfused compared to the left ventricle?
The right Ventricle is perfused throughout systole and diastole but flow to the left ventricle is largely limited to diastole
44
What all can decrease coronary perfusion?
decreased aortic pressure
increased LVEDP
increased HR
45
Two kinds of hypertrophy of the myocardium, what are they?
concentric (pressure) and eccentric (volume) hypertrophy.
46
what is concentric hypertrophy?
pressure will increase the thickness of the myocardium wall but does not increase chamber size.
47
What is Eccentric hypertrophy?
volume will increase the size by literally increasing the size of the heart chamber but not so much the mass/thickness of the wall.
48
Due to chronically elevated afterload describes?
Concentric hypertrophy (pressure overload)
49
Due to chronically elevated preload describes?
Eccentric hypertrophy (volume overload)
50
volume pressure loop that is longer than taller shows what?
increasing preload
51
volume pressure loop that is taller than it is long shows what?
increasing afterload
52
How does the P-V loop change in systolic failure?
diastolic portion of the P-V loop has shifted to the right.
53
How does the P-V loop change in diastolic failure?
diastolic portion of the P-V loop has shifted up.
54
What chamber of the heart is affected by mitral valve stenosis
The left atrium must work harder to push blood through the damaged valve and enlarges as a result.
55
What is normal left atrial pressure?
8 is normal
56
If you have mitral stenosis what will your left atrial pressure look like?
25/14 (high), increased wedge pressure
57
P-V loop of mitral stenosis looks like what?
everything is decreased bc their is less filling of the left ventricle
58
What valve issue can cause pulmonary congestion, coughing up blood with extreme congestion?
Mitral Stenosis
59
With mitral stenosis what is going on with the left ventricle?
LV is typically perfect!
60
symptoms of mitral stenosis?
Dyspnea, orthopnea , PND (due to pul. congestion) “backup”
Hemoptysis
A. fib leading to embolization
61
Medical therapy for mitral stenosis?
Diuretics for pulmonary congestion
Digoxin
Anticoagulant
62
Anesthetic concerns with someone who has mitral stenosis?
Maintain sinus rhythm , avoid tachycardia
Tachycardia decreases diastolic time leading to lesser filling
Avoid fluid overload and hypovolumia
Avoid spinal/epidural nerve block
Afterload reduction
Beta blockers for tachycardia
Diltiazem and digoxin in A fib
Phenylephrine as vasoconstrictor
63
How do you want the HR for mitral stenosis?
slow (low HR), this allows time for blood to fill the left ventricle.
64
What do you want the rhythm to be with mitral stenosis?
regular
65
What valve issue causes straightening of the left border of the heart?
mitral stenosis
66
What is valvular regurgitation?
when blood leaks in the wrong direction bc one or more of the heart valves closes improperly.
67
What does the P-V loop look like with chronic mitral valve regurgitation?
very large a oddly shaped, goes really far to the right.
68
what happens in mitral regurgitation?
the mitral valve is incompetent and when blood is pumped from the LV into the aortic valve the mitral valve allows blood back into the left atrium
69
What can rheumatic heart disease cause?
mitral regurgitation
70
mitral regurgitation will cause a decrease in what?
decreased CO (50% SV may be regurgitated)
71
How does the LV compensate for mitral regurgitation?
by dilating and increasing LVEDV (maintains CO despite decrease in SV)
72
Most patients with mitral regurgitation have a combination of what two cardiac issues?
pulmonary congestion plus low cardiac output
73
Diffuse and hyperdynamic ventricular impulse
Holosystolic murmur best heard at apex, radiating to axilla
Wide splitting S2
S3 due to volume overload in left atrium
This describes what?
Mitral regurgitation
74
left atrial enlargement and left ventricular hypertrophy describes findings of what?
Mitral regurgitation
75
Goal of medical therapy with mitral regurgitation?
increase forward flow by reducing afterload.
| Reduce pulmonary venous congestion.
76
Drugs that help with mitral regurgitation?
Vasodilator e.g. ACE inhibitors
Digoxin to ventricular rate in A fib ( digoxin prolong conduction through AV node )
Diuretics
Anti-coagulant to prevent embolization
77
mid-diastolic click describes what valve issue?
Mitral valve prolapse
78
Is treatment needed for mitral valve prolapse?
No treatment needed for this condition.
79
Most frequent valvular lesion, especially in younger women would be?
Mitral valve prolapse
80
what type of murmur is produced from mitral valve prolapse?
murmur of mitral regurgitation
81
What anesthesia meds do you want to avoid in someone with mitral valve prolapse?
Avoid agents that increases heart rate or release histamine
Select non-depolarizing muscle relaxant that does not have circulatory effect
82
Rheumatic fever can cause?
aortic stenosis
83
Where does aortic stenosis occur?
aortic valve, this is where the coronary arteries come in at to give the heart it's blood supply.
84
The aortic valve is stenosed, thus what happens?
very high pressure gradient between aorta and LV
85
dilation of the ascending aorta, calcification of the aortic valve and hypertrophy of the LV would cause what to be diagnosed?
aortic stenosis
86
LVESP = 200 mmHg
| increased LVESV, LVEDV and decreased SV would mean?
aortic stenosis
87
Normal aortic valve measurements are?
| Stenotic aortic valve would have a measurement of?
Normal = 2.5-3.5cm squared
stenotic aortic valve = 0.7-0.9 cm squared (less than one cm squared)
88
How does the P-V loop move in aortic stenosis?
upward and to the right
89
Is aortic stenosis an acute obstruction or gradual?
gradual obstruction that allows the left ventricle to compensate and maintain SV
90
Clinical symptoms of Aortic stenosis?
Angina w/o CAD is due to decreased O2 supply to the sub-endocardium by decreasing ventricular diastolic compliance
Syncope and faintness
Dyspnea on exertion
91
Do the coronary arteries feed the heart during diastole or systole?
diastole
92
What is the therapy a person with aortic stenosis needs?
aortic valve replacement
93
What is contraindicated with aortic stenosis?
Spinal and epidural anesthetics are contraindicated in severe stenosis can lead to decrease in systemic vascular resistance
94
What do you have to WATCH out for with aortic stenosis?
WATCH OUT FOR VASODILATION because it is associated with large reduction in blood pressure and coronary blood flow
95
What is the pressor of choice for hypotension with aortic stenosis?
Phenylephrine
96
What do you need to remember with aortic stenosis?
```
Slow (low heart rate)
Full (maintain or increase preload)
Tight (maintain or increase afterload)
To maintain coronary perfusion pressure
Regular (maintain sinus rhythm)
Not too strong (maintain contractility)
```
97
aortic regurgitation will change the P V loop how?
no relaxation and no contraction bc blood is still coming down during systole, large curve that is very circular.
98
causes of aortic regurgitation?
```
Rheumatic heart disease or congenital
Infective endocarditis
3 degree Syphilis
Aortic dissection
Marfan’s syndrome
Collagen vascular disease e.g. SLE
```
99
aortic regurgitation would cause what to happen to the pulse pressure?
widened pulse pressure (160/50)
100
What drives perfusion of the coronary arteries?
diastolic pressure, thus in aortic regurgitation when diastolic pressure is decreased you may have angina due to decreased coronary blood to the heart.
101
Post MI you can get what syndrome?
Dressler's syndrome
102
*What is Dressler's syndrome?
Immune reaction against necrotic myocardium, causes inflammation of the pericardium.
103
*What type of EKG findings might a pt. have with acute pericarditis?
tachycardia
| diffuse ST segment elevation (important)
104
Pulsus paradoxus?
decrease systolic BP > 10 mmHg during inspiration (normal drop is 6 mmHg)
105
Kussmaul's sign?
distension of JVP during inspiration
106
pulses paradoxus and kussmaul's sign typically occur with what heart issue?
cardiac tamponade
107
Constrictive pericarditis treatment is?
surgical stripping
108
type A aneurysms involve?
| type B aneurysms involve?
```
A= ascending aorta
B= does not involve the ascending aorta
```
109
What is Takayasu arteritis?
A type of systemic vasculitis. Inflammation of aorta and major vessels, causing weak pulse.
110
S/S of Takayasu arteritis?
upper extremity claudication, angina, CHF, absent pulses, arterial bruits, BP differences btwn two arms.
young asian women are at higher risk
111
What is temporal arteritis?
ischemia of vessels in the carotid artery region and include unilateral headache, visual disturbance (impairment of ophthalmic artery) and jaw claudication – “sore jaw”
112
Tx for temporal arteritis?
Steroids to prevent Blindness
113
What is Buerger's dz, what are the symptoms, and treatment?
Inflammation of small and medium sized arteries
Smoker’s disease
Foot claudication
Leg pain, ulceration , skin necrosis
Treatment: Choose one; your legs or cigarette
114
What is Wegener's granulomatosis, Diagnosis and treatment?
Triad of upper and lower airway disease and renal disease- glumerulonephritis
Sinusitis and hematuria
Dx: ANCA (antineutrophilic cytoplasmic antibodies)
Tx
Cyclophosphamide, steroid and/or methotrexate
115
What is polyarteritis nodosa, treatment?
Involves medium-sized arteries in kidneys , gut , skin
S/S: fever, weight loss, malaise, abdominal pain,melena, headache, myalgia,hypertension and cutaneous erruption
Microaneurysms on angiography
Treatment: cyclophosphamide, steroid
116
What is kawasaki dz, s/s, treatment?
Acute, self-limiting necrotizing vasulitis in infants/children.
In Asian population
Fever, conjunctivits, changes in lips/oral mucosa “strawberry tongue”, lymphadenitis, desqumative rash
Treatment: aspirin , immunoglobulins
117
DVT may give rise to what? (bad)
PE
118
Tx for DVT?
Anticoagulation
| Thrombolytic therapy
119
In someone who has CAD and a third heart sound, what does that show?
global ischemia
120
In the first 6 hours of MI what is the gold standard for diagnosis?
EKG
121
When is Cardiac troponin I used?
4 hours after cardiac ischemia and up to 7-10 days after.
122
ST elevation shows?
transmural ischemia
123
Q waves show?
transmural infarct
124
Myoglobin is used for what time period after infarct?
less than 2 hours
125
Indications for cardiac catheterization?
Suspicion of severe or extensive CAD
Marked positive stress test
Failure to respond to medical management
126
tearing chest pain radiating to back with normal EKG would indicate?
Aortic dissection
127
Angina pectoris how much CAD narrowing?
>75%
128
stable angina ?
is usually precipitated by physical exertion and is relieved by rest and/ or nitrates.
129
Unstable angina?
refers to pain that occurs at rest, or without a provoking cause. New dramatic onset. Most ominous sign of CAD. Risk of MI
130
NON cardiovascular causes of angina?
```
Esophageal disease e.g. reflux
PUD
Biliary disease e.g. gall stones
Musculoskeletal disease e.g. costochondritis
Pleurisy
Pulmonary infarction
Pneumothorax
```
131
cardiovascular causes of angina?
Aortic stenosis
Pericarditis
Aortic dissection
132
Treatment for unstable angina?
Hospitalization “ ROMI”
IV Nitroglycerine
Aspirin and anti-platelet therapy to prevent thrombus
Patients who don’t stabilize with medical therapy should undergo cardiac cath for revascularization
133
Prinzmetal's angina hallmark symptom, associated with, and treatment?
Angina at rest that is associated with ST segment elevation (hallmark)
2° to coronary artery spasm
Associated with Reynold’s disease
Treatment with nitrates and Ca++ channel blockers to treat vasospasm
134
In who does silent ischemia tend to occur? Treatment?
diabetics
| Tx is nitrates and calcium channel blockers
135
How do Ca++ channel blockers relieve angina?
by decreasing afterload, HR, and contractility
136
What is the most potent calcium channel blocker?
| what is the order of potent calcium channel blockers?
Verapamil is the most potent in lowering HR and decreasing contractility.
Verapamil>diltiazem>nifedipine
137
How do Beta blockers treat CAD?
Decrease HR
Decrease BP
Decrease contractility resulting in decreased 02 consumption.
138
What medication is useful in exercise induced ischemia (most useful for this)?
beta blockers
139
Beta blockers should be avoided in what conditions with CAD?
Bronchial spasm
CHF
Bradycardia
140
How do diuretics and ACE inhibitors help CAD?
Decrease myocardial 02 demand
141
How do nitrates relieve angina?
venodilation which decreases cardiac wall tension
142
What over the counter medication can reduce the risk of MI in patients with CAD?
Low dose aspirin
143
CABG improves survival in patients with? (3 answers)
Left main coronary disease Left main=OR
Triple vessel disease
EF < 50%
144
overall success rate of angioplasty is?
Restenosis rate is?
When is it performed?
overall success rate is 80-90%
restenosis rate = 30%
single or two vessels disease poorly controlled with meds would call for angioplasty.
145
Most Common Cause of acute MI is?
chronic coronary atherosclerosis
146
acute MI most often occurs in what three vessels (greatest to least)
LAD>RCA>circumflex
147
In RVF the lungs are congested or clear?
clear
148
typical clinical presentation of acute MI?
Severe persistent anginal PAIN > 30 MINUTES ; pain in left arm , jaw, SOB, fatigue, adrenergic symptoms.
149
During acute MI tachycardia would be due to?
pump failure, anxiety, pericarditis
150
During acute MI bradycardia would be due to?
inferior wall MI (RCA) or increased vagal tone
151
Increased JVP during acute MI is due to?
right ventricular failure or bi-ventricular failure. in RVF lungs are clear
152
what heart sound tells you "volume overload"
S3
153
ST elevation tells you?
transmural ischemia
154
Q wave tells you?
transmural infarct
155
what is the test (lab) of choice in the first 24 hours post MI?
CK-MB
156
When does a CK-MB return to normal?
72-96 hours
157
persistent elevation of a CK-MB shows what?
post infarct ischemia- DO CATH.
158
Acute management for MI, remember what to do with what acronym?
```
BOOMAR :
Bed rest
Oxygen
Opiate
Monitoring
Anticoagulation
Reduce clot size
```
159
Thrombolytic therapy would include what two drugs?
tpa
| streptokinase
160
thrombolytic therapy is most useful in what time frame?
1 HOUR onset of symptoms, success rate is 50-75%, decreases after 6 hours
161
does first degree heart block require therapy?
Rarely requires surgery
162
In which heartblock is a pacemaker indicated?
mobitz type II
163
In which heartblock is pacemaker not indicated?
Mobitz type I
164
both RBBB and LBBB require what temporarily?
pacemaker
165
Most common cause of death after Acute MI is?
cardiac arrhythmias (90%)
