Cardiovascular Pathophysiology Flashcards by Ashley Campbell

Coronary autoregulation occurs with MAP between what?

60-140 mmHg

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In HTN, the autoregulation curve is shifted to the _______ (right/left)

Right

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In HTN, try to keep patients within ____% of their preoperative blood pressure throughout the perioperative phase

20%

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HTN is associated with ____ ventricular hypertrophy

Left

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METS > ____ is reassuring sign that patients will do ok with anesthesia

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Patients with DBP greater than _____ mmHg have a significantly increased risk of cardiac morbidity; consider cancelling case

110

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HTN

Use of ____ and ____ can cause refractory hypotension during case

ACE inhibitors, ARBs

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HTN

Consider DCing ACE inhibitors and ARBs ____ h prior to surgery to reduce the risk of intraoperative _________ (no adverse cardiac events or mortality if held)

24 h

hypotension

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HTN

Should a Beta-blocker be held on day of surgery?

NO. Preoperative antihypertensives should be continued up to and including the day of surgery

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Patients with HTN have an ________ response during induction of anesthesia, laryngoscopy, surgical stimulation, etc.

Exaggerated

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HTN

Induction agents can cause _________ d/t hypovolemia

Consider combination of low dose induction agents vs larger single one (ex: propofol/ketamine)

hypotension

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HTN

Laryngoscopy/intubation can cause ________

Consider greater depth of anesthesia, beta blocker

Exaggerated hypertension

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HTN

Drugs used for refractory hypotension

Vasopressin
Methylene blue

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HTN

What might you consider ordering post-op for hyperdynamic, hypertensive state?

Hydralazine 10mg IVP
Labetalol 5mg IVP

Demerol 25 mg (shivering)

Pain control

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Acute pericarditis most common cause

Viral infection

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Acute peridcarditis

Chronic, extended organization of fibrinous exudate can lead to: ______________ and ___________

Chronic constrictive pericarditis
Cardiac tamponade

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Condition characterized by:

sudden onset chest pain
(pleuritic)
diffuse st segment elevation
normal cardiac enzymes

Acute pericarditis

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Anesthetic management of acute pericarditis

No change, in absence of pericardial effusion

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Chronic constrictive pericarditis most common cause

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Chronic constrictive pericarditis

Stiff, fibrous tissue encircles the heart, limiting _______

diastole

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Chronic constrictive pericarditis

Abnormal ____________ -both ventricles

Diastolic filling

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Chronic constrictive pericarditis

Pulmonary and peripheral congestion lead to ______ (Increased/decreased) CVP

Increased

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Primary ____ and ____ are most common valvular dysfunctions that lead to the most severe hemodynamic impairments

MV, AV

Mitral valve, aortic valve

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Mitral Stenosis

Severe disease when mitral valve < _____ cm2

1.0 cm2

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Mitral Stenosis Chronically ____________ LV

Underfilled

Mitral Stenosis ____ (increased/decreased) SVR

Increased d/t compensation for low CO

Mitral Stenosis Increased LA pressure/volume leads to increased risk of _______

a.fib

Avoid ___________ (tachycardia/bradycardia) in regurgitant lesions because it can significantly __________ regurgitant fraction and reduce overall SV

bradycardia, increase

Avoid _________ (tachycardia/bradycardia) with STENOTIC lesions d/t shortened filling and ejection times, will reduce SV and increase oxygen demand

Tachycardia

Mitral stenosis Increased LA pressures can eventually lead to ___ failure, (cor _______)

RV, cor pulmonale

Chronic constrictive pericarditis and cardiac tamponade associated with ___________ (when sbp decreases during inspiration)

Pulsus paradoxus

in chronic constrictive pericarditis, engorged neck veins, hepatomegaly, ascites, peripheral edema are signs of?

Increased venous pressure (CVP) and congestion

Chronic constrictive pericarditis anesthetic mangement HR

Avoid bradycardia (CO dependent on HR; impaired diastolic filling and limited SV)

Chronic constrictive pericarditis anesthetic mangement Medication that can preserve CO

Ketamine

Chronic constrictive pericarditis anesthetic mangement Cautious use of __________ to avoid myocardial depression

Volatile agents

Chronic constrictive pericarditis anesthetic mangement Afterload

Maintain

Chronic constrictive pericarditis anesthetic mangement PPV

PPV can reduce CO (Increased intrathoracic pressure)

Cardiac tamponade leads to impairment of __________ filling

diastolic

In cardiac tamponade, accumulation of pericardial fluid leads to _________ congestion and decrease in CO and SV

peripheral

Cardiac tamponade Beck's triad

1. Hypotension 2. JVD 3. Muffled heart sounds

Cardiac tamponade Kussmaul's sign

Increased CVP and JVD during inspiration

Best method to diagnose cardiac tamponade

TEE

Cardiac tamponade CXR

Enlarged cardiac silhouette

Cardiac tamponade treatment

Pericardiocentesis Pericardiostomy

Cardiac tamponade anesthetic management Local or general anesthesia?

Local preferred (GA high risk d/t further myocardial depression from volatile anesthetics, PPV

Cardiac tamponade anesthetic management General anesthesia is a _____ (high/low) risk for these patients

High (further myocardial depression)

Cardiac tamponade anesthetic management HR

Avoid bradycardia (CO = HR X SV , SV already impaired)

Cardiac tamponade anesthetic management Afterload

Maintain

Hypertrophic cardiomyopathy left ventricular _________ resulting in _________ (decreased/increased) left chamber size

hypertrophy, decreased

Hypertrophic cardiomyopathy Left ventricular hypertrophy and decreased LV results in a ________

LV outflow tract obstruction (LVOT)

Hypertrophic cardiomyopathy Causes ________ and ________ dysfunction

Systolic and diastolic

Hypertrophic cardiomyopathy Asymmetric _________ of the interventricular septum causes LVOT

hypertrophy

Hypertrophic cardiomyopathy What can further obstruct LV outflow if present?

Systolic anterior motion (SAM) of mitral valve leaflet

Hypertrophic cardiomyopathy anesthetic management Preload

Maintain

Hypertrophic cardiomyopathy anesthetic management Contractility

Myocardial depression desirable BBs, CCB (decreases obstruction on LVOT)

Hypertrophic cardiomyopathy anesthetic management Limit use of __________ because myocardial depression is desireable

ephedrine, epinephrine

Hypertrophic cardiomyopathy anesthetic management HR

Promptly treat afib or junctional rhythm Avoid tachycardia Isuprel (beta agonist) may be given during surgery to increase LV/Ao gradient

Hypertrophic cardiomyopathy anesthetic management Afterload

Maintain/increase PHENYLEPHRINE (resistance dependent on outflow tract, so ok to increase SVR if hypotensive)

Dilated cardiomyopathy causes ________ hypertrophy of both the right and left ventricles

eccentric

Dilated cardiomyopathy causes _______ and _______ dysfunction

systolic and diastolic

Dilated cardiomyopathy correlated with _____ and _____ regurgitation

MV and/or TV

Dilated cardiomyopathy Progression of leads to _______ contractility and ________

decreased, CHF

Dilated cardiomyopathy anesthetic considerations Afterload

Afterload reduction

Dilated cardiomyopathy anesthetic considerations Preload

Avoid large fluid bolus

Dilated cardiomyopathy anesthetic considerations Contractility

avoid myocardial depression neuraxial anesthesia etomidate for IV induction

Restrictive cardiomyopathy one or more ventricles becomes stiff and _______ d/t fibrous tissue and deposits

non-compliant

Restrictive cardiomyopathy Leads to impaired __________

diastolic filling

Restrictive cardiomyopathy anesthetic considerations Intravenous ________ support may be necessary (ex: ________)

inotropic epinephrine

Restrictive cardiomyopathy anesthetic considerations Consider use of _____ and hemodynamic monitoring

TEE

Restrictive cardiomyopathy anesthetic considerations Choose anesthetic techniques that will reduce overall myocardial ___________

Depression

A more rare form of cardiomyopathy caused by genetic predisposition, sarcoidosis, hemochromatosis, endomyocardial fibrosis

Restrictive cardiomyopathy

Restrictive cardiomyopathy ________ diastolic filling -----> decreased__________volumes-------> decreased _____

Impaired, end diastolic, SV

Restrictive cardiomyopathy Clinical presentation

Dyspnea, fatigue, cardiomegaly, JVD, pulmonary HTN, rales