Cardiovascular Anesthesia Pt. 1 (Exam III)

Question 1

What are some risk factors for CAD?

Answer 1

• Male
• Age
• ↑ cholesterol
• HTN
• Smoking
• DM
• Obesity
• Sedentary lifestyle
• Genetics
• Personality/Stress

Question 2

Angina is an imbalance between myocardial _____ and ______.

Answer 2

demand & supply

Question 3

What is the pain pathway of angina?

Answer 3

Partially occluded coronary artery
→ Adenosine, bradykinin, lactic acid release
→ nociceptive receptors w/ afferent neurons to upper five thoracic sympathetic ganglia
→ thalamic & cortical stimulation = pain

Question 4

Which spinal levels are responsible for myocardial pain receptors?

Answer 4

Thoracic 1 - 5

Question 5

What are the two types of angina?

Answer 5

• Chronic (stable) angina = no change in pain intensity or duration over 2 months
• Unstable = pain at rest or increasing in severity/frequency

Question 6

What two EKG changes are often indicative of subendocardial ischemia?

Answer 6

• ST segment depression
• Transient T-wave depression

Question 7

What is the name of the point where the transition from the QRS to the ST-segment occurs?

Answer 7

J-Point

Question 8

What are the three types of ST-Segment depression?

Answer 8

• Up-sloping
• Down-sloping
• Horizontal

Question 9

What type of ST-segment depression is most likely to be related to coronary disease?

Answer 9

Horizontal ST depression

Question 10

More ST depression = ______ likelihood of significant CAD.

Answer 10

higher

Question 11

What diagnostic test assesses coronary perfusion and has greater sensitivity for ischemia than exercise testing?

Answer 11

Nuclear stress test

Question 12

Which tracers are used with nuclear stress testing?

Answer 12

Thallium & Technetium

Question 13

What would an absent uptake of nuclear stress test tracers indicate?

Answer 13

Old MI (fibrous tissue)

Question 14

What would an significant uptake of nuclear stress test tracers indicate?

Answer 14

normal circulation

Question 15

What would a decreased uptake of nuclear stress test tracers indicate?

Answer 15

Perfusion abnormality

Question 16

How is non-exercise nuclear stress testing done?

Answer 16

Induced tachycardia w/

• Atropine
• Dobutamine
• Pacing

Question 17

Which two drugs are coronary dilators used in nuclear stress testing?

Answer 17

Adenosine
Dipyridamole

Question 18

What type of coronary plaque is considered unstable?

Answer 18

Large lipid core with thin cover

Very likely to rupture.

Question 19

What does aspirin inhibit?

Answer 19

COX-1
Thromboxane A2

Question 20

How long does the effect of platelet inhibition due to aspirin last?

Answer 20

For the life of the platelet (irreversible)

Question 21

What is the “lifespan” of a human platelet?

Answer 21

7 - 10 days

Question 22

How does Clopidogrel (Plavix) work?

Answer 22

Inhibition of ADP receptor (P2Y₁₂)

Question 23

What drug class can greatly change the effects of Plavix due to enzyme inhibition?

Answer 23

PPI’s

Question 24

What drug is similar to clopidogrel in the following:

• Requires P450 enzyme for conversion from prodrug to active metabolite
• Inhibits ADP P2Y₁₂

Answer 24

Prasugrel (Effient)

Question 25

What are the pros & cons of Prasugrel vs Plavix?

Answer 25

Prasugrel Pros: - Rapidly absorbed - Faster onset - Less individual variability Cons: - Higher risk of bleeding (much more potent)

Question 26

What two conditions were mentioned in lecture as contraindications for nitrate administration?

Answer 26

- Hypertrophic Cardiomyopathy - Aortic Stenosis

Question 27

Nitrates have a synergistic effect with what drug classes?

Answer 27

β blockers & CCB's

Question 28

What are the effects of nitrates?

Answer 28

- Subendocardial artery dilation - ↓ SVR - ↓ afterload - ↓ myocardial O₂ consumption

Question 29

Which two cardiac disease processes necessitate a maintenance of a high afterload?

Answer 29

- Hypertrophic Cardiomyopathy - Aortic Stenosis

Question 30

Can nitrates be given around the clock?

Answer 30

No, 8 - 12 hours of the day need to be nitrate free. **Sensitization occurs w/ around the clock therapy**.

Question 31

What is the principal drug for stable angina?

Answer 31

β blockers

Question 32

How do β blockers improve coronary perfusion?

Answer 32

- ↓ myocardial O₂ demand - ↑ diastole time

Question 33

In what scenarios are β blockers contraindicated?

Answer 33

- Severe bradycardia - Sick sinus syndrome - Severe Asthma - 2ⁿᵈ & 3ʳᵈ degree heart block - Uncontrolled CHF

Question 34

What common cardiac drug class will mask the signs of hypoglycemia?

Answer 34

β blockers

Question 35

What are the SCIP protocol measures for β blockers?

Answer 35

- If already on β blocker, must receive dose within 24 hours of surgery - If not on β blocker, do not initiate unless 1-4 weeks out from non-cardiac surgery.

Question 36

What type of calcium channels do CCB's bind to?

Answer 36

L-type Ca⁺⁺ channels

Question 37

Where are the effects of L-type Ca⁺⁺ channel blockade seen?

Answer 37

- Smooth muscle - Cardiac Myocytes - SA/AV nodes

Question 38

Are β blockers or CCB's more effective in prevention of MI?

Answer 38

β blockers

Question 39

What type of angina are CCBs most useful for?

Answer 39

Prinzmetal's Angina

Question 40

What is Prinzmetal's angina?

Answer 40

Vasospasm related angina (not related to atherosclerosis)

Question 41

Angiotensin II promotes inflammatory response and what other deleterious cardiac effects?

Answer 41

- Atheroma formation - Coronary vasoconstriction - Myocardial hypertrophy

Question 42

ACE inhibitors are indicated for patients with CAD and what other concurrent diseases?

Answer 42

- HTN - LV dysfunction - DM

Question 43

What antihypertensive is held within 24 hours of anesthesia? Why?

Answer 43

ACE Inhibitors (compounds hypotension from anesthesia).

Question 44

What is the mortality of STEMI without early reperfusion therapy? How about with reperfusion therapy?

Answer 44

- 20% without - 6.5% with reperfusion therapy

Question 45

What is MONA?

Answer 45

**M**orphine **O**xygen **N**itrates **A**spirin

Question 46

According to lecture, what is an NSTEMI?

Answer 46

No ST-elevation but: - New-onset severe and/or prolonged angina - Angina at rest for more than 20 min

Question 47

How are NSTEMI's diagnosed?

Answer 47

- ↑ biomarkers - ST depression and/or T-wave inversion w/ **pain**.

Question 48

What is the major difference in treatment of STEMI vs NSTEMI?

Answer 48

**No thrombolytics (tPa) for NSTEMI patients**

Question 49

What is the most common cause of death in acute MI?

Answer 49

Cardiac Dysrhythmias

Question 50

If ventricular tachycardia is asymptomatic, how can it be treated?

Answer 50

Lidocaine and/or amiodarone

Question 51

What are the most common atrial dysrhythmias?

Answer 51

Afib / Aflutter

Question 52

What decreases the occurrence of atrial dysrhythmias during/after MI?

Answer 52

Thrombolytics

Question 53

What type of MI is commonly seen with sinus bradycardia?

Answer 53

Inferior wall MI

Question 54

When does pericarditis typically occur after an MI?

Answer 54

1 - 4 days post MI

Question 55

What position worsens pericarditis pain?

Answer 55

Lying down

Question 56

Diffuse ST-segment changes would likely indicate ________.

Answer 56

Pericarditis

Question 57

How is pericarditis treated?

Answer 57

- ASA - Indomethacin - Steroids

Question 58

If pericarditis becomes chronic after an MI, it is called ________ syndrome.

Answer 58

Dressler's Syndrome

Question 59

What can occur from ischemic injury causing rupture of the papillary muscles?

Answer 59

Mitral regurgitation

Question 60

An MI in which wall makes mitral regurgitation much more likely?

Answer 60

Inferior wall MI (can result in papillary muscle rupture).

Question 61

What is the treatment for Mitral Regurgitation?

Answer 61

- ↓ LV Afterload (diuretics, nitrates) - ↑ Coronary perfusion (IABP, consider valve repair)

Question 62

In order to have significant cardiogenic shock, usually ____ % or more of the myocardium must be infarcted.

Answer 62

40% or more

Question 63

Where is the tip of a IABP positioned?

Answer 63

Just below the Left Subclavian artery

Question 64

When does an IABP inflate & deflate?

Answer 64

- Inflate during ventricular diastole - Deflate just prior to ventricular systole

Question 65

What are contraindications to IABP placement?

Answer 65

- **Severe aortic insufficiency** - Aortic Aneurysm - Severe PAD - Severe Coagulopathy

Question 66

What are the possible complications of IABP?

Answer 66

- Limb Ischemia - Aortic Dissection - Hemorrhage - Helium Emboli - Infection

Question 67

KNOW 12 LEAD EKG DIAGNOSES

Answer 67

Question 68

When are bare-metal coronary stents more appropriate than drug-eluting stents?

Answer 68

In patients who need urgent surgeries

Question 69

What is inhibited by drug-eluting stents?

Answer 69

- Clotting - Neointimal Hyperplasia

Question 70

What makes drug-eluting stent placement much more risky?

Answer 70

If antiplatelet therapy is discontinued in 1st year

Question 71

What is the general risk with coronary stenting?

Answer 71

- Mechanically opening a blood vessel injures the endothelium and increases the risk of thrombosis

Question 72

How long does re-endothelialization occur (according to current DAPT guidelines) with the following: - Angioplasty - Bare-metal stents - Drug-eluting stents

Answer 72

- 2 weeks - 6 weeks - 3 months

Question 73

What pathologies have shown increased mortality in studies in patients who are who are on DAPT?

Answer 73

- Spinal Cord pathologies - Aneurysm - Prostatectomy

Question 74

Look up DAPT & Neuraxial Interventions

Question 75

What are the indications for CABG surgery?

Answer 75

- Medical therapy failure - LM > 50% obstructed - EF <40% w/ significant disease - 3 or more diseased vessels

Question 76

When is emergency CABG surgery indicated?

Answer 76

- Failed angioplasty - MI septal rupture - MI mitral regurgitation - Perforated coronary artery - Cardiogenic shock