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APEX > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

Describe the function of the Na/K Pump

A

-maintains the cell’s RMP by keeping the inside of the cell (-) and the outside of the cell (+)
-Removes 3 Na+, brings in 2 K+

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2
Q

List the five phases of ventricular action potential

A

Phase 0 = depolarization = Na influx

Phase 1 = initial repolarization = K efflux and Cl influx

Phase 2 = plateau = calcium influx

Phase 3 = repolarization = k+ efflux

Phase 4 = Na+ / K + pump restores RMP

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3
Q

List 3 phases of the SA node action potential

A

Phase 4 = Spontaneous Depolarization = Leaky to Na+ (Ca+ influx at the end of phase 4)

Phase 0 = Depolarization = Ca influx

Phase 3 = Repolarization = K Efflux

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4
Q

What process determines the intrinsic heart rate, and what physiologic factors alter it?

A

The rate of spontaneous phase 4 depolarization in the SA node determines heart rate. It can be increased by:
1. Rate of phase 4 increases (reaches TP faster)
2. TP becomes more negative (shorter distance between RMP and TP)
3. RMP becomes less negative

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5
Q

What is the calculation for mean arterial blood pressure?

A

(CO x SVR)/80 + CVP

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6
Q

What is the formula for PVR?

A

(MPAP - PAOP)/CO x 80

normal = 150 - 250 dynes/s/cm-5

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7
Q

Describe the Frank-Starling relationship

A

The relationship between ventricular volume and ventricular output (CO)

Ventricular volume = CVP, PAD, PAOP, LAP, LVEDP, RVEDV, LVEDV

CO = SV, LVSW, RVSW

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8
Q

What factors affect myocardial contractility?

A

Chemicals affect contractility, particularly calcium!!

Increased Contractility = Dig, PDEi
Decreased Contractility = HyperK

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9
Q

Discuss the cardiomyocyte contractility steps

A
  1. Depol of T-Tubule opens VG L-type calcium channels. calcium enters myocyte. (phase 2 of the AP)
  2. Calcium influx activates RyR2 receptors.
  3. Calcium is released from the SR.
  4. Calcium binds to troponin C. Stimulates CB formation.
  5. Calcoium unbinds from troponin C.
  6. Most of the calcium is returned to the SR via SERCA2 pump (ATP dependent). Once inside. Calcium binds to calsequestrin (storage protein)
  7. Some of the calcium is removed from the myocyte by sodium/calcium exchange pump.
  8. Na/K ATPase restores RMP.
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10
Q

How to calculate SVR

A

MAP - CVP / CO X 80

normal = 800 - 1500 dynes/sec/cm2

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11
Q

What law can be applied to afterload?

A

Law of Laplace

Wall stress = (Intraventricular pressure x radius) / Ventricular thickness

intraventricular pressure = the force that pushes the heart apart
wall stress= the force that holds the heart together

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12
Q

List 3 conditions that set afterload proximal to the systemic circulation

A
  1. Aortic Stenosis
  2. Coarctation of the aorta
  3. Hypertrophic CM
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13
Q

How to calculate EF?

A

Stroke Volume / EDV x 100

mild dysfunction = 41 - 49%
mod = 26 - 40%
severe < 25%

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14
Q

What is the best TEE view for diagnosing myocardial ischemia?

A

Midpapillary muscle level in short axis

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15
Q

What is the equation for CPP?

A

AoDBP - LVED

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16
Q

What region of the heart is most susceptible to MI? Why?

A

LV subendocardium d/t high compressive tissue in LV

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17
Q

Steps in the NO pathway

A
  1. NO synthase catalyzes the conversion of L-arginine to NO
  2. NO diffuses from the endothelium to the smooth muscle
  3. NO activates guanylate cyclase.
  4. GC converts guanosine triphosphate (GT) to cyclic guanosine monophosphate (cGMP)
  5. Increased cGMP reduces intracellular calcium
  6. PDE deactivates cGMP to guanosine monophosphate to turn off NO
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18
Q

What does S3 & S4 suggest

A

S3 = heart failure, flaccid & inelastic heart. Heard during middle 1/3 of diastole. Gallop rhythm (rumbling)
S4 = decreased ventricular compliance, caused by atrial systole. Heard before S1.

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19
Q

What does S1 mean

A

-Closure of mitral and tricuspid valves.
-Marks the onset of systole
-End of LV filling and beginning of isovolumetric contraction

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20
Q

What does S2 mean

A

-Closure of aortic and pulmonic valves
-Marks onset of diastole
-End of LV ejection and beginning of isovolumetric relaxation

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21
Q

Stenosis Valve

A

Sarcomeres added in parallel
Concentric hypertrophy d/t pressure overload

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22
Q

Regurgitant valve

A

Sarcomeres added in series
Eccentric hypertrophy

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23
Q

List the hemodynamic goals Aortic Stenosis

A
  • slow/nml HR
  • high preload
  • high SVR
    -nml PVR & contractility
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24
Q

HD Goals for Mitral Stenosis

A

-slow/nml HR
-avoid an increase in PVR
-keep everything else nml.

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25
Q

AI goals

A

-HR high
-Preload high
-Low SVR
-nml PVR & contractility

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26
Q

mitral insufficiency goals

A

-HR high
-Preload high
-Contractility nml
-SVR low
-Avoid an increase in PVR

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27
Q

what is the most common dysrhythmia associated w/mitral stenosis?

A

a fibb

28
Q

List 6 risk factors for perioperative cardiac m&m for non-cardiac surgery

A

-High risk surgery
-Hx of IHD
-Hx of CHF
-Hx of cerebral vascular dx
-DM
-Cr > 2 mg/dL

29
Q

Risk of periop MI

A

Gen pop = 0.3%
MI if > 6 mo = 6%
MI if 3 - 6 mo = 15%
MI < 3 mo = 30%

highest risk of reinfarction is wi/i 30 days of an acute MI recommends 4 - 6 weeks

30
Q

High, medium, low-risk procedures

A

High (> 5%)
-emergent, open aorta, PVD sx, long

Intermediate (1-5%)
-CEA, head/neck, intrathoracic, ortho, prostate

Low (<1%)
-endoscopic, cataract, superficial, breast, ambulatory

31
Q

How do you interpret cardiac enzymes in a patient w/suspected ischemic event

A

-Troponins are more sensitive than CK-MB
-All enzymes initial elevation is w/i 3 - 12 hours

CK MB peaks @ 24 hours, baseline in 3 days
Trop. I peaks @ 24 hours, baseline in 5-10d
Trop. T peaks @12-48h, baseline in 5-14d

32
Q

How do you treat an intraoperative MI?

A

make the heart SLOWER, SMALLER, AND BETTER PERFUSED

-BB to keep HR < 80
-Incr. depth of anesthesia, vasodilate (nitro)
-Avoid an increased PAOP

33
Q

What factors reduce ventricular compliance?

A

Age > 60
Ischemia
Pressure overload hypertrophy
Hypertrophic obstructive CM
Pericardial pressure

34
Q

What is the difference btw HFrEF and HFpEF

A

HFrEF (systolic failure) = decreased EF with increased end-diastolic volume. Volume overload commonly causes systolic dysfunction

HFpEF (diastolic failure) = heart cannot relax and accept the incoming volume because ventricular compliance is reduced. Symptomatic heart failure with a normal EF.

35
Q

HD goals for HFrEF

A

Preload = already high
Afterload = decrease (SNP), maintain CPP tho
Contractility = augment with inotropes (dobutamine)
HR = usually high d/t incr’d SNS tone. If EF is low, than a higher HR is needed to preserve EF

36
Q

HD goals for HFpEF

A

Preload = volume required to stretch noncompliant ventricle. LVEDP does NOT correlate with LVEDV!!
Afterload = keep elevated to perfuse a thick myocardium
Contractility = normal
HR = slow/normal to increase diastolic time and CPP

37
Q

NY Heart Failure Classification

A

Class 1 - no s/s
2 - s/s with moderate activity
3 - s/s with mild activity
4 - s/s at rest

38
Q

List 6 complications of HTN

A

LVH
IHD
CHF
Arterial aneurysm
Stroke
End-stage renal dx

39
Q

Primary vs. secondary hypertension

A

Primary is more common and has no identifiable cause (95%)

Secondary is caused by some other pathology

40
Q

Name 7 causes of secondary hypertension

A
  1. Coarctation of the aorta
  2. Renovascular disease
  3. Cushing’s (adrenocorticism)
  4. Conn’s (aldosterone)
  5. Pheo
  6. Pregnancy-induced hypertension
41
Q

What are the 2 major classes of CCBs

A

Dihydropyridines - targets VSM
-Vasodilation

Non-dihydropyridines - targets myocardium
-Decreased heart rate, contractility, conduction, and coronary vascular resistance

42
Q

Name the non-dihydropyridines

A

Verapmail = phenylalkylamine
Diltiazem = benzothiazepine

43
Q

Anesthetic management of constrictive pericarditis

A

-CO is dependent on HR - avoid bradycardia
-Preserve HR and contractility (Ketamine, Pancuronium, Opioids, benzos, etomidate)
-Maintain afterload

44
Q

What is Kussmaul’s sign

A

Impaired RV filling d/t poorly compliant RV or pericardium. Blood backs up. = JVD, and increased CVP … esp during inspiration

45
Q

What is pulsus paradoxus

A

Exaggerated drop in SBP during inspiration (> 10 mm Hg) which suggests impaired diastolic filling

*Negative intrathoracic pressure on inspiration = increased venous return to RV = bowing of ventricular septum towards LV = decreased SV

46
Q

Kussmauls & Pulsus paraadoxus are present with

A

constrictive pericarditis
pericardial tamponade

47
Q

Anesthetic considerations for the patient w/acute tamponade

A

Local anesthesia is preferred
Any drug that depresses the myocardium or reduces afterload will result in CV collapse

-Avoid = IA, propofol, neuraxial
-Safe = ketamine, nitrous, benzos, low-dose opioids

48
Q

List 7 patient factors that warrent abx prophylaxis for endocarditis

A

-Hx endocarditis
-Prosthetic heart valve
-Unrepaired cyanotic congenital heart dx
-Repaired congenital heart dx < 6 mo. old
-Impaired endothelialization at the graft site
-Heart tx w/valvuloplasty

49
Q

3 surgeries that warrent abx prophylaxis against endocarditis

A
  1. dental w/gingival manipulation
  2. resp. with mucosal lining perf
  3. biopsy of infected lesion
50
Q

3 key determinants of flow thru LVOT

A
  1. systolic LV volume
  2. force of LV contraction
  3. transmural pressure gradient
51
Q

What factors reduce CO with obstructive hypertrophic cardiomyopathy

A
  1. low systolic volume (low preload or high HR)
  2. high contractility
  3. low transmural pressure (Aortic DBP low)
52
Q

How long should elective sx be delayed in the patient with a PCI?

A

12 months for all DES

Angioplasty w/o stent = 2 - 4 weeks
Bare Metal = 30 days
DES w/stable IHD = 1st gen 12 mo, 2nd gen 6 mo
DES w/ACS = 12 mo
CABG = 6 weeks

53
Q

What is the difference btw alpha stat and pH stat?

A

Alpha stat - does not take into consideration the patient’s temperature. Better outcomes for adults.

pH stat takes into consideration the patient’s temperature. Better outcomes for peds.

as temp decreases, more CO2 will dissolve in the blood

54
Q

Why is a LV vent used during CABG?

A

Removes blood from the LV from thebesian veins and bronchial circulation

55
Q

How does the IABP work?

A

Deflates during systole - decreases afterload, correlates w/R wave on EKG
Inflates during diastole - increases coronary perfusion, correlates w/dicrotic notch

56
Q

4 c/i to IABP

A

severe AI
descending aortic dx
severe PVD
sepsis

57
Q

Discuss the Crawford classification

A

Used to assess aortic aneurysms r/t thoracic and abdominal aorta

I. descending thoracic aorta & upper abd.
II. thoracic & most abdominal
III. lower thoracic & most abd.
IV. abdominal only

2 and 3 are the most difficult to repair

58
Q

DeBakey and Stanford

A

Classifies the aortic dissection

Stanford
A - involves ascending aorta
B - does not involve ascending aorta

DeBakey
1. Tear in AA and dissection along entire aorta
2. Tear in AA and dissection in AA
3. Tear in proximal descending aorta

59
Q

Which law describes aortic diameter & rupture

A

Law of Laplace

Wall tension = transmural pressure x vessel radius

Mortality increases significantly once AAA reaches 5.5 cm (sx recommended if growing > 0.6 - 0.8 cm / year)

60
Q

How does the AoX contribute to anterior spinal artery syndrome

A

If its clamped above the artery of Adamkiewicz ischemia can occur to lower portion of anterior spinal cord.

Beck’s syndrome = anterior spinal artery syndrome

61
Q

S/S of Beck’s syndrome

A

Flaccid paralysis of LE
Impaired bowel/bladder function
Loss of temp/pain

preserved touch & propioception

62
Q

What is amaurosis fugax?

A

Blindness in one eye = s/s of impending stroke

63
Q

EEG monitoring for CEA

A

EEG monitors cortical electrical function
Risk of cerebral hypoperfusion w/ loss of amplitude, decreased beta wave, and/or slow wave

HIGH incidence of false negative d/t increased or decreased frequency

64
Q

Increased Hz during EEG

A

-mild hypercarbia
-early hypoxia
-sz or ketamine
-nitrous
-light

65
Q

Decreased Hz during EEG

A

-extreme hypercarbia
-hypoxia
-cerebral ischemia
-hypothermia
-anesthetic OD
-opioids

66
Q

CEA regional

A

must block C2 - C4

cervical plexus block!!

APEX (18 decks)

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